ML20116J920
| ML20116J920 | |
| Person / Time | |
|---|---|
| Issue date: | 09/30/1992 |
| From: | NRC OFFICE FOR ANALYSIS & EVALUATION OF OPERATIONAL DATA (AEOD) |
| To: | |
| References | |
| NUREG-1303, NUREG-1303-R02, NUREG-1303-R2, NUDOCS 9211160448 | |
| Download: ML20116J920 (149) | |
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l NUREG-1303 L
Rev. 2-f, Incident Investigation Manual i
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U.S. Nuclear Regulatory Commission Office for Analysis and Evaluation of Operational Data pn arov
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9211160448 920930 PDR NUREG PDR 1303 R
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UNITED STATES 8
NUCLEAR REGULATORY COMMISSION o
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NOTICE TO RECIPIENTS OF NUREG 1303. Rev. 2 This revision replaces the entire report and Appendices A, j
B, and C (retain index tabs through Appendix C).
Remove Appendices D and E and the index tabs for these i
j two Appendices.
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O NUREG-1303 Rev.2 Incident Investigation Manual Manusenpt Completed: Jur.e 1992 Date Published: September 1992 OIYice for Analysis and Evaluation of Operational Data U.S. Nuclear Regulatory Commission Washington, DC 20555
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AVAILABILITY NOTICE l
Availability of Reference Materials Cited in NRC Publications Most documents cited in NRC publications will be available from one of the following sources:
1.
The NRC Public Document Room, 2120 L Street, NW., Lower t.evel, Washington, DC 20555 2.
The Superintendent of Documents, U.S. Government Printing O'fice, P.O. Box 37082, Washington, DC 20013-7082 3.
The National Technical Information Service, Springfield, VA 22161 Although the listing that follows represents the majority of documents cited in NRC publica-tions, it is not intended to be exhaustive.
Referenced documents available for inspection and copying for a fee from the NRC Public Document Room include NRC correspondence and internal NRC memoranda: NRC bulletins, circulars, information notices, inspection and investigation notices; licensee event reports; vendor reports and correspondence; Commission papers; and applicant and licensee docu-ments and correspondence.
The following documents in the NUREG series are available for purchase from the GPO Sales Program: formal NRC staff and contractor reports, NRC-sponsored conference proceed-ings, international agreement reports, grant publications ind NRC booklets and brochures.
Also evailable are regu'atory guides, NRC regulat.ons in the Code of Federal Regulations, and Nuclear Regulatory Commission Itsuances.
Documents available from the National Technical InforNion Service include NUREG-series reports and technical reports prepared by other Federal agencies and reports prepared by trie Atomic Energy Commission, forerunner agency to the Nuclear Regulatory Commission.
Documents available from public and special technical libraries include all open literature items, such as books, journal articles, and transactions. Federal Register notices, Federal and State legislation, and congressional reports can usually be obtained from these libraries.
Documents such as theses, dissertations. foreign reports and translations, and non-NRC conference proceedings are available for purchase from the organization sponsoring the publication cited.
Single copieu of NRC draft reports are available free, to the extent of supply, upon written request to the Office of Administration, Distribution and Mail Services Section, U.S. Nuclear Regulatory Commission, Washington, DC 20555.
Copies of industry codes and standards used in a substan ive manner in the NRC regulatory process are maintained at the NRC Library, 7920 Norfolk Avenue, Bethesda, Maryland, for use by the public. Codes and standards are usually copyrighted and may be purchased from the originating organization or, if they are American National Standards, from the American National Standards Institute,1430 Broadway, New York, NY 10018.
ABSTRACT The Incident Investigation Manual prescribes guidelines for the conduct of investigative activities of the U.S. Nuclear Regulatory Cor.. mission (NRC) Incident Investigation Teams c
(llTs). The purpose of this manual is to provide IITs guidance to ensure that NRC investigations of significant events are timely, structured, coordinated, and formally administered. The guidelines are intended to assist the investigation rather than limit the initiatives and good judgment of the IIT leader or members. The IIT leader and team members should use their experience and those techniques that provide the most confidence in assuring the IIT objectives are achieved. These guidelines address IIT activation, conduct of the investigation, conducting interviews, treatment of quarantined equipment and areas, preparation of the team report and followup of staff actions.
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\\BLE OF CONTENTS 4
A BST RA CT.........................................
iii PREFACE ix GUIDELINE 1: ACT'VATING AN INCIDENT INVESTIGATION TEAhi.....
1-1 1.1 Purpose 1-1 1.2 Background..........................
1-1 1.3 Selection and Scope of Events for IIT Response..............
1-2 1.4 IIT Discussion and Activation Process....................
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1.5 Scope of the Investigation 1-6 1.6 Team Selection and Composition.......................
1-7 1.7 Participation by Industry Organizations...................
1-7 1.8 Role of the Region During Activation....................
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1.9 Upgrading or Downgrading an ~ "estigation.................
1-10 1.10 Ex hibi ts....................................... 1 12 Generic Confirmatory Action Letter......................
1-12 Generic Order hiodifying License 1-14 Background Information (compiled by the Region) for the.
4 IIT Briefing Package........,..................
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Example EDO Memorandum to the Commission..............
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NRC Region I Mobile Nondestructive Evaluation Laboratory 1-23 l
Agreement on Waiver of Compensation, Conflicts of Interest i
and Release of Investigation Information for Industry Representatives Participating in Incident Investigation Teams (IITs)..................
1-27 EDO Memorandum on Waiver of Commission Policy on Avoidance of Organizational Conflicts of Interest for Industry Participants.........................
1-31 Region Action Item Checklist for Activating an IIT 1-33 GUIDELINE 2: CONDUCTING AN INCIDENT INVESTIGATION 2-1
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2.1 Purpose 2-1 2.2 Background....................................
2-1 2.3 IIT Leader Responsibilities 2-1 2.4 Role of the Region in Support of the Conduct of the Incident Investigation 2-4 2.5 Initial Actions by the IIT Leader.......................
2-4 2.6 Entrance Meeting with the Licensee.....................
2-5 2.7 Plant Tour of Affected Equipment and Systems..............
2-7 2.8 Interviewing Personnel......................,
2-8 j p 2.9 Sequence o f Events....................,..........
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2.10 Quarantined Equipment List (QEL) and Troub.eshooting Action Plans (TA Ps)........
2-9 2.11 IIT Coordination Meetings...........................
2-9 2.12 Status Reports and Event Briefings......................
2-9 2.13 Collection of Information and Recordkeeping Activities.........
2-10 2.14 Responding to Press Inquiries.........................
2-10 2.15 Identifying Additional Expertise and Outside Assistance..........
2-11 2.16 Industry Participation in the Investigation................... 2-11 2.17 Parallel Investigations..
2-11 2.18 Referral of Investigation Information to NRC Offices 2-12 2.19 Protecting an Individual's identity....................... 2-12 2.20 Subpoena Power and Power to Administer Oath and Affirmation 2-13 2.21 Return Site Visit.................................. 2-13 2.22 Report Preparation and Presentation...................... 2-13 2.23 Exhibits...
2-14 IIT Team Leader Checklist 2-14 Press Conference Guidance 2-16 Generic Bulletin Board Notice 2-17 Example IIT Preliminary Sequence of Events................ 2-18 Example Preliminary Notification Report................... 2-21 GUIDELINE 3: CONDUCTING INTERVIEWS.............,,.......
3-1 3.1 Purpose 3-1 3.2 Background......
3-1 3.3 Scheduling and Team Attendance..
3-2 3.4 Third Party Attendance.............................
3-2 3.5 Interview Guidelines 3-3 3.6 Exhibits 3-5 Guidelines for Review and Availability of Transcripts..........
3-5 GUIDELINE 4: TREATMENT OF QUARANTINED EQUIPMENT.........
4-1 4.1 Purpose 4-1 4.2 Background............
4-1 4.3 Quarantined Equipment List (QEL) 4-2 4.4 Troubleshooting Action Plans.........................
4-3 4.5 Ex h ib i ts......................................
4-f Generic Guidelines for Troubleshooting the Probable Causes of Equipment Anomalies.............
4-6 Example Troubleshooting Action Plan (TAP) 4-8 i
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GUIDELINE 5: PREPARATION OF THE INCIDENT INVESTIGATION TEAM REPORT AND FOLLOWUP STAFF ACTIONS 5-1 i
5-1 5.1 Purpose 5.2 Background........................
5-1 5.3 Writing and Publishing Guidelines............
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2.4 Report Writing Guidelines....................
5-1 5.5 Graphic Guidelines 5-4 5.6 Publicati.on Form s................................
5-5 5.7 Distribution of the Advance Copy..........,...........
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5.8 Distribution of the Published NUREG....................
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5.9 Staff Action Determination and Assignment 5-6 5.10 Staff Action Status Reporting.........................
5-7 5.11 S c h ed u l e......................................
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5.12 Ex h i b i t s......................................
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1 Example Report Outline............................
5-10 IIT Team Leader Checklist 5-12 Example Staff Actions 5-13 1
4 APPENDICES i
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NRC Incident Investigation Program, Management Directive 8.3 i
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Augmented Inspection Team, NRC Inspection Manual Chapter 0325 C.
letter from W. J. Dircks, to the Commissioners,
Subject:
Incident Investigation Program, i
SECY-85-208, dated June 10, 1985.
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PREFACE i
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The objective of the Incident Investigation Program (llP)is to ensure that operational significant events are investigated in a systematic and technically sound manner to gather information pertaining to the probable causes of the events, including any NRC contributions or lapses, and to provide appropt
.e feedback regarding the lessons of experience to the NRC, industry, and public. By focusing on probable causes of operating events and i
identification of associated corrective actions, the results of the llP process improve nuclear safety by ensuring a complete technical and regulatory understanding of significant events.
1 Incident Investigation Teams ensure that significant operational events are investigated in a manner that is timely, objective, systematic and technically sound; that factual information pertaining to the event is documented; that probable cause(' are ascertained; and that a complete technical and regulatory understanding of such an event is achieved.
l These guidelines were dcveloped and organized by the Office for Analysis and Evaluation of Operational Data (AEOD). In early 1986, a draft of the guidelines were provided to all the owner's groups, the Institute of Nuclear Power Operations (INPO), and the Nuclear Safety -
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Analysis Center (NSAC) for comment. Between January 29,1987 and March 11, 1987, AEOD held five regional workshops to acquaint licensees with the IIP. In August 1991, the i
guidelines were revised to clearly define the roles and responsioilities of the team leader, provide guidance on the followup and closecut of NRC staff actions, address lessons learned from incident investigations, and incorporate more current illustrative exhibits. The guidelines were also revi:ed to address changes incorporated into NRC Management Directive 8.3, "NRC Incident Investigation Program" (formerly NRC Manual Chapter 0513).
i' These guidelines will foster uniformity, consistency, and thoroughness in IIT investigations, while permitting teams the flexibility to accommodate the diverse nature and scope of future investigations.
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GUIDELINE 1: ACTIVATING AN
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INCIDENT INVESl'lGATION TEAM (IIT) l.1 Purpose Guideline 1 provides guidance to NRC management for activating an incident Inve3dgation Team (llT) response to a significant operational event at an NRC-licensed facility. This guideline rdso provides direction for activating an llT and selecting the number and kinJs of expertise required for a timely,.'horough, and systematic investigation.
1.2 Background
The scope, objectives, authorities, responsibilitics, and basic requirements for t'te investigation of significant operational events at reactor and nonreat a facilities licensed by the NRC are defined in "NRC Inciden! Investigation Program," Management Directive 8.3 (see Appendix A). The Executive Director for Operations (EDO) approves the investigation of a significant orv rational event by an llT, in part, on the basis of recommendations by NRC he aquartos and regional offices concerning the safety significance of the event. The EDO also determines the composition of the llT and approves team mernbers (including composition) based on recommendations by senior NRC management.
The incident Ir migation Program encompases investigatory responses by an llT and the
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less formal response by an Augmented Inspection Team (AIT). The major differences between an AIT and an llT are that.
an llT ' westigates the most safety-significant operational events relative to the risk ti
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the llT 4. ider and members have not had significant involvement with licensing and inspection activities at the affected facility, and industry representatives m.,, participate on an IIT under the provisions of a e
Memorandum of Agreement between NRC and the Institute of Nuclear Power Operations (INPO).
Events of lesser safety significance whose facts, conditions, circumstances, and probable causes would contrib,
to the regulatory and technical understanding of a generic safety concern or another important lesson will be assessed by an AIT. NRC Inspection Manual Chapter 0325, " Augmented Inspection Team," is the procedure for activating and conducting an AIT response, maic.ained by the Office of Nuclear Reactor Regulation (NRR) (see Appendix B).
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A 1.3 Selection and Segne of Events for IIT Respong The recommendation to the EDO for activating an llT should include the identification of the potential safety significance of the event. The threshold for activating an llT is intended to be high and limited to those operational events which are expected to have significant safety implications llistorically, the events investigated by an llT have generally involved multiple failures in plant systems, which resulted in system responses that were not part of the design bases, and substantially reduced the safety margins that ensure public health and safety.
Significant operational events tMt should be considered for an llT response may include one or more of the following characteristics:
(1)
Led to a significant release of radioactive material to unrestricted areas, or oserexposure of personnel to radioactive material.
A significant overexposure or release of radioactive material is an event which substantially exceeds the regulatory limits in 10 CFR Part 20, or has the potential for significant radiation or chemical exposure to members of the public. Such events include those which can occur at both reactor and nonreactor facilities, and transportation events subject to NRC jurisdiction. In evaluating these events, primary attention should focus on the onsite and offsite personnel health and safety concerns, and consider the offsite protective actions, and the potential generic aspects of the event. The inadvertent shipment of a radiographic source Som Korea to Amersham Corporation, Builington, Massachusetts, in 1990 is an example of an event of this type. An llT was established because of the nature and potential radiological health consequences and the generic questions the event raised. The UF6 cylinder rupture at the Sequoyah Fuels Facility in 1986 also falls in this category because of the large release of hydrogen fluoride (a reaction product of UF6 and airborne moisture) to the environment, and the involvement of multiple agencies in response to the event. Potential offsite (i.e., public health) radiological consequences are a primary concern and thus, should public health and safety be significantly impacted or threatened, an IIT response would be appropriate.
(2)
Involved operation that exceeded, or was outside of the design bases of the facility.
Such events include those where a valid challenge existed yet both trains of a safety-related system were lost, or events that were not analyzed in the Updated Safety Analysis Report; e.g., the loss of offsite power and failure of onsite power on demand at Vogtle (1990), the total loss of feedwater at Davis-Besse (1985), the precursor anticipated transient without scram (ATWS) at Salem (1983), the failure on demand of the safety injection system at San Onofre (1981), and the f% at Dmwns Ferry (1975).
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(3)
Involved an apparent major deficiency in design, construction or operation hav.ng potential generic safety implications.
Events with this characteristic would include an unplanned criticality, or multiple failures in safety eq"ipment or procedural controls that had a-signincant potential for an ung.anned criticality. An unplanned criticality is a condition whereby fissionable materials are unintentionally assembled so as to produce an uncontrolled chain reaction. Such events include those which can occur at fuel cycle facilities, such as fuel processing and fabrication plants, and at power and nonpower reactor facilities, in general, reactor operations involving approaches to criticality, where criticality is either achieved unexpectedly or not achieved as expected, will not fall within this criterion if operations are within established limits.
Examples of events involving a major deficiency in design or operation having significant potential safety implications include the loss of integrated control system at Rancho Seco (1985), the water hammer event at San Onofre (1985),
the failure of the reactor cavity seal at Haddam Neck (1984), the inadvertent criticalities during refueling with the reactor vessel head removed at Millstone-(1976) and Vermont Yankee (1973).
(4)
Led to a site area emergency.
This type elevent would involve activation of the NRC Operations Center and would normally involve multi agency responses. Examples of such events include the loss of offsite power and failure of onsite power on demand at Vogtle in 1990, and the UF6 cylinder rupture at the Sequoyah Fuels Facility m 1986.
(5)
Exceeded a safety limit of the licensee's Technical Specifications.
Safety limits are defined for each *eactor in the technical specifications, e.gl for a pressurized water reactor (PWR), reactor coolant system pressure exceeding the maximum allowable, or the combination of thermal power, pres-surizer pressure, and the appropriate limit for n and n-1 loop operation. An example for a boiling water reactor (BWR) was the Oyster Creek loss of coolant event (1979) which exceeded the safety limit for minimum core inventory water level requirements.
(6)
Led to a significant loss of fuel ir.tegrity, the primary coolant pressure boundary, or the primary containment boundary of a nuclear reactor.
Examples of events with this characteristic include the steam generator tube rupture at Ginna (1982), the loss of coolant outside the containment structure 1-3
at flatch (1982), and significant reactor coolant pump seal leaks at Robinson (1981) and Arkansas Nuclear One (1980).
(7)
Led to the loss of a safety function or multiple failures in systems used to mitigate an actual event.
Examples of evera * 'h this characteristic include the failure of the auxiliary feedwater systen J % 'is-Ilesse (1985), the partial failure to scram at Browns Ferry (1980), th
. ssor ATWS event at Salem (1983), and the failure of the safety injection system on demand at San Onofre (1981).
(8)
Involved circumstances sufficiently complex, unique, or not well enough understood, or involved safeguards concerns, or involved characteristics the investigation of which would best serve the necils and interests of the Commission.
1.4 llLDiscussion and AcliYaliRDBECM Activating an llT in response to a signincant operating event at a power reactor normally involves the coordinated activities of the appropriate Region, ACOD, NRR, and the EDO. If the affected facility involves fuel cycle, byproduct material, uranium recovery, or waste management licensees, the Of0cc of Nuclear hiaterial Safety and Safeguards (NhtSS) would also participate. The decision to activate an llT should include consideration of public health and safety (protection of public/ environment from radioactive release or contamination) and be based en the safety issues, potential generic implications, personnel errors, or equipment failures associated with the event related to the characteristics discussed in Section 1.3.
The IIT is activated and will begin its investigation as soon as practical after the safety significance of the operational event is determined to ensure that the facts, conditions, circumstances, and probable causes are ascertained. If there is an NRC incident response, the investigation will begin after the incident response is deactivated.
The following guidelines should be used to recommend and activate an llT:
(1)
Upon their notincation of a signincant operational event, the Directors of NRR or NhtSS, AEOD, and the Regional Administrator should jointly discuss and assess the safety significance of the event to determine whether an IIT or an AIT is required.
For activating IITs, they should assess the level of investigatory response based on the j
criteria in NRC hianagement Directive 8.3 (see Appendix A) and this guideline, and for AITs, they should use the criteria in NRC Inspection hianual Chapter 0325, Augmented Inspection Team (see Appendix B),
(2)
Regional Administrators, in coordination with NRR or NhtSS, are to determine thase i
operational events warranting investigation by an AIT; and as soon as it becomes clear that at least an AIT is warranted, preferably before an AIT is actually 1-4
established, consult with the Directors of NRR or NMSS, and AEOD to consider wh:ther an llT response is appropriate, if an llT is agreed upon, the initiating ofSce makes that recommendation to the EDO. Differences among offices concerning whether an AIT or IIT is the proper response are submitted to the EDO for resobtion.
(3; For events which the EDO agrees warrant an llT, the EDO selects the llT leader and team members (see Section 1.6). The Director, AEOD* will take the lead in coordinating with NRR or NMSS, and the appropriate Regional Administrator regard-ing the expertise and the availability of individuals, and the preparation of the team's written charter delineating the scope of the investigation, for approval by the EDO (see Section 1.5). For reactor events, the Director, AEOD, will contact the Group Vice President for Industry and Government Relations, INPO, who will coordinate with various industry groups to facilitate industry partichation on the llT (see Section 1.7).
(4)
The EDO assigns a due date for the report of about 45 days after the IIT has been activated. The EDO should consider assigning the due date to coincide with a Monday so that all available administrative support will be directed to preparing the final report during the preceding weekend.
(5)
After the llT leader and members have been selected, AEOD provides the administra-tive support necessary to dispatch the IIT in a timely manner. This support includes travel authorizations, tickets and advances during off-duty hours, logistics, and other site-specific information, including site access, and other site arrangements. AEOD staff will accompany and provide administrative support to the llT.
(6)
The Regional Administrator issues a Confirmatory Action Letter (as illustrated by Exhibit 1-1) to the affected licensee. The Confirmatory Action Letter (CAL) confirms a licensee's statement of intent and action. In the unlikely event that the licensee and Regional Office cannot agree on the actions that the NRC believes are necessary, the Director of NRR may issue an Order ensuring that information related to the event is preserved. Exhibit 1-2 shows a generic Order. Even where the licensee agrees to the terms of the CAL, those commitments may be confirmed by Order at a later time if NRC management deems it appropriate.
(7)
The Regional Administrator will designate a regional representative to interface with the llT. The regional representative should initially ensure that a briefing package is available to the IIT when it arrives onsite (see Exhibit 1-3).
- The Director, AEOD may designate another senior AEOD manager to be responsible for carrying out office functions related to the llT.
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(8)
The Director, AEOD prepares for the EDO's signature a memorandum informing the Commission of the activation of an llT and the scope of the investigation (team charter). Exhibit 1-4 shows an example memorandum. The Director, AEOD also contacts the Director, Of6ce of Public Affairs (OPA) and assists in the preparation of the NRC press release.
J l.5 Scene of the investigatioJ1 Following the decision to activate an llT, the scope of the investigation should be quickly evaluated and documented in the form of a team charter. The scope of an llT investigation should include conditions preceding the event, event chronology, systems response, human factors considerations, equipment peiformance, precursors to the event, emergency response (NRC and licensee), safety significance, radiological considerations, and whether the regulatory process and activities preceding the event contributed to it. A detailed team charter delineating the scope of the investigation will be provided to the llT leader. The charter should be provided as an enclosure to the EDO's memorandum notifying the Commission that an llT has been established (see Exhibit 1-4). The basis for the IIT shall be included in the written charter.
The scope of the investigation shall nel include:
specinc assessment of violations of NRC rules and requirements; review of the design and licensing bases for the facility, except as necessary to assess the cause for the event under investigation; assessment of reasonable assurance of offsite emergency response capabilities of State and local agencies; or determination for resumption of licensed operation.
Information collected as part of the llT process may contribute to a decision to resume facility operations prior to issuance of the llT report. Such instances require close coordination between the IIT leader, the Regional Administrator, and the appropriate program office director.
Followup actions associated with the llP process do not necessarily include all licensee actions associated with the event, nor oo they cover NRC staff activities associated with normal event followup (such as authorization for restart, plant inspections, corrective actions, or possible enforcement items). These activities are expected to be defined and implemented through the normal organizational structures and procedures. NRC staff may utilize / review information obtained during the 11T investigation, including transcripts, and may request guidance from IIT members on matters concerning actions associated with the llT report / investigation as input to or as part of separate investigations.
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l.6 Icam Selection and Composition in addition to identifying the potential safety significance of the event, the recommendation to the EDO for activating an llT investigation should address the types of expertise needed for the team. The llT membership selection should be based on the following guidelines:
(1)
Determine the number of team members and their areas of technical expertise based on the type of.'acility and characteristics of the event. For a teactor event, the team may include experts in reactor systems, human factors, operations (liccased operator),
and mechanical or electrical systems. Additional members could include specialists in core physics, radiological assessment, health physics, chemistry, materials, safeguards, emergency preparedness, or other specialized areas.
(2)
Select the llT leader (who is an NRC manager from the Senior Executive Service (SES)) and team members based on their expertise, potential for contributing to the event investigation, freedom from significant involvement in the licensing and inspection of the facility involved or other activities associated with issues that had a direct impact on the course or consequences of the event, and full time participation for the duration of IIT activities. To the extent practical, select the IIT leader ano team members from approved rosters of candidates maintained by AEOD. Candidates should be certified through the completion of formal training in incident investigation.
AEOD will provide an administrative coordinator as a team member, trained in IIT administrative functions, to support the team for the duration of the investigation until issuance of the final report.
(3)
Obtain technical contract support for the llT as needed. Contractor assistance should be limited to services that are not available within the NRC, e.g., independent laboratory analyses, computational support and testing. Within the NRC, there are also capabilities and expertise that can contribute to the llT activities, e.g., the NDE van and equipment (see Exhibit 1-5 for description of NDE van equipment capabil-ities), control room simulators, photography, and computer analyses. AEOD will provide the resources and administrative support necessary to procure the services requested by the team leader. The Assistant General Counsel for Hearings and Enforcement will provide legal assistance as necessary. As requested by the IIT leader, AEOD will provide a staff member with expert knowledge of IIT procedures to support the team during the investigation.
1.7 Earticipation by Industry Organizationt When an IIT is activated for a power reactor event, industry representatives should be informed and their participation should be encouraged. Their participation brings both an industry perspective to the investigation and expert knowledge of plant hardware and practices in numerous areas, in addition, industry participation would facilitate in the feedback of factual information regarding the event to the industry for the self-initiation of i
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potential preventive and/or corrective actions. Such participation should also help expedite the event investigation and the identiGeation of the generic applicability of signincant issues.
Industry participation is consistent with and fully supportive of the incident Investigation r
Program objectives.
After the EDO determines that an llT response is warranted, the Director, AEOD should contact the Group Vice President for Industry and Government Relations, Institute of Nuclear Power Operations (INPO), who will inform the various industry groups (Nuclear Safety Analysis Center (NSAC) and the owners' group for the affected plant) regarding the llT and coordinate their participatiori with the IIT in the investigation. The Director, AEOD may t
indicate the type of technical expertise that would be desirable for the industry representative to have in order to ensure a proper range of disciplines on the llT. The Group Vice
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President for Industry and Government Relations, INPO will be the contact with NRC to recommend the industry representative (s) using the same criteria by which the NRC uses to
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select NRC members, i.e., (1) specine technical expertise; (2) potential for contributing to the event investigation; (3) no previous signincant involvement with the affected plant or utility's activities or with other significant issues associated with or directly related to the cause, course or consequences of the event; and (4) fe 'ime participation for the duration of IIT activities. As part of its nomination of industry pamcipants, INPO will submit a statement signed by each industry nominee regarding proprietary informatio., con 0icts of imcrest, procedures for handling differences of opinion and procedures for handling release of information. A signed statement by the nominees to these agreements v:ill be provided to the NRC as part of the nomination process (Exhibit 1-6).
The industry representatives' and the NRC members' quali6 cations will be reviewed by the EDO or upon his direction, the Director, AEOD to ensure that all team members are suitably quali6ed and meet the selection criteria. The EDO approves the llT members on a case-by-case basis (i.e., each is reviewed and approved individually). In addition, pursuant to the waiver procedures specined in 41 CFR Part 201.54, " Contractor Organizational Conflicts of Interest," the waiver regarding the policy of avoiding organizational conflicts of interest provided in Exhibit 1-7 should be executed for the purposes of allowing the participation of industry personnel on NRC IITs.
After the EDO approves the composition and membership of the llT, all members will be advised of the location and time for the first IIT organizational meeting. The Group Vice President for Industry and Government Relations, INPO will be requested to provide assistance in coordinating with the affected licensee in obtaining site access for the industry representatives. The llT leader will organize and assign the various investigative activities to NRC team members. All representatives should be relieved of other duties until the investigation is completed and the investigation report is issued. The EDO may relieve from the llT any personnel who will not remain with the investigation until the completion of the report, or other personnel for reasons he deems appropriate.
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The NRC has a policy which addresses attendance of State representatives at NRC meetings with licensees and allows for agreements with States for observation or participation in routine plant inspections. These agreements do not apply to llTs. Requests by State and/or l
local officials to be involved in an llT will be handled on a case-by-case basis. Non NRC IIT members are expected from organizations directly involved with the analysis and l
cvaluation of operational experience, such as INPO. As noted above, representatives from non NRC organizations would be expected to have the same level of qualifications as NRC personnel and be selected in accordance with the same criteria by which NRC personnel are selected.
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](ole of the Region DutiDg Activation A region action item checklist for activating an llT is provided in Exhibit 18. The responsibilities of the Region related to an llT activation are to:
(1)
Provide input to the discussion and decision process on recommending the need for activating an llT.
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_(2)
Provide input to the Director, AEOD regarding the desired expertise and the llT's--
written charter delineating the scope of the investigation.
(3)
Designate a regional representative to coordinate regional activities with the llT.
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(4)
Issue a CAL (as illustrated by Exhibit 1-1) to the affected licensee confirming the licensee's commitment that, within the constraints of ensuring safety, relevant failed equipment and areas are quarantined and subject to agreed upon controls; that information related to the event is preserved; and that the facility is maintained in a safe condition until concurrence is received from the NRC to resume facility operations. Completion of an llT investigation and issuance of the report is not necessarily required for resumption of facility operations.
(5)
Prepare a brienng package prior to the IIT's arrival. This package should provide sufficient backgiound information for IIT members 20 quickly grasp unique aspects of the plant design and relevant data relatec' to the event. The regional representative should coordinate with the llT team leader on the briefing package information necessary to support the IIT For power reactors, this type of information should be readily available from the resident inspector's office, where most of the data would normally be compiled as part of the resident inspector's onsite followup to significant events. Exhibit 1-3 lists information that could be provided in the briefing package.
Prepare to present a briefing on the event and related information to the team upon their site arrival.
19
(6)
Provide public affairs assistance, as needed. This includes conferring with the Director of Public Affairs, licadquarters, about the need for a Public Affairs Officer onsite.
l (7)
Make appropriate State notifications.
(8)
Negotiate with the licensee for sufficient office space for the llT. If arrangements cannot be made to locate the team onsite, the Region should identify an alternate location as close to the site as possible. Accommodations should include:
4 a conference room with adequate space to house the IIT, e
at least two rooms for conducting interviews, e
adequate number of telephones (including at least one conference call and/or 3
speaker telephone), and an additional area for reviewing transcripts and performing administrative e
functions.
(9)
Provide administrative support, which could include:
obtaining transcription services, providing full-time secretarial support for llT administrative workload, and e
obtaining escorted or unescorted site access for team members, as determined by the team leader.
(10)
Coordinate the entrance meeting and plant tour for the llT with the licensee.
1.9 Upgmding or Dovinemdi.pg an Investigation Adequate information is not always initially available or accurate enough to determine whether the safety significance of an event warrants an AIT or an IIT. Thus, an investigation could be subsequently upgraded or downgraded based on evolving available information, in general, the safety significance of the event will be the criterion guiding the investigatory response.
Upgrading or downgrading of an investigation can confuse the licensee and cause additional disruption to ongoing activities. Accordingly, the llT leader must minimize the adverse impact of such a change by ensuring that frequent and meaningful communication occurs among the AIT, IIT, and the licensee during the critical transition period.
1-10
The following guidelines are used to upgrade an AIT to an llT:
(1)
In defining the scope of art AIT investigation, the Regional Administrator includes a provision for the AIT leader to continually evaluate the safety significance of the event after arriving onsite. Based on the AIT leader's assessment, the Regional Administrator determines whether the event warrants consideration as a candidate for an llT response.
(2)
Should the Regional Administrator determine that the event warrants consideration as an llT response, the process for activating an llT would be followed as described previously in this guideline, e.g., a conference call would be held between the Region, NRR or NMSS, and AEOD (and possibly the AIT leader).
(3)
The AIT teader would usually be replaced by an llT leader selected by the EDO; nowever, all or some AIT members may be retained for the llT based primarily on the independence of the individual with respect to their prior activities related to the affected licensee and the issues involved in the event.
(4)
- The AIT remains onsite to assist the llT until the llT leader believes that a successful transition has been achieved.
The following guidelines are usei.o downgrade an llT to an AIT:
(1)
In consultation with the llT leader, the EDO decides that the event lacks the safety significance to warrant continuance as an llT.
(2)
The EDO assigns responsibility to the Regional Administrator to direct the llT to AIT transition, including the release of the IIT leader, industry representatives, and some or all of the NRC team members.
(3)
The ifT leader is usually replaced by an AIT leader selected by the Regional
- Administrator.
(4)
The AIT follows the NRC Inspection Manual Inspectica Procedure 93800, which guides the response of the AIT.
(5)
The Director, AEOD, prepares a memorandum for the EDO's signature informing the Commission that the llT has been deactivated based on the lesser safety significance of the event. The Director, OpA, is also informed at this time.
1-11 J
l 1.10 Exhibits Exhibit 1 1 Gennie Confirmatory Action LeitgI 1
Docket No.
[ Licensee Name]
[ Address)
==Dear
.:==
On [date], [brief description of event]. Because of the potential signincance of this incident to public health and safety, the NRC's Executive Director for Operations has established an incident Investigation Team (IIT) to investigate the circumstances surrounding the incident.
[ Include as appropriate a brief description of the event's significance).
This letter connrms the conversation on [date) between and of my staff related to this incident. With regard to the matters discussed, we understand that you have agreed to co perate with the llT and you have taken or will promptly take the following actions necessary to support this investigation:
(1)
The facility will remain in cold shutdown [or other appropriate mode description]
until the Regional Administrator is satisfied that appropriate corrective action has been taken and the plant can safely return to operation.
(2)
The licensee will prepare a list of equipment that failed or malfunctioned during the event and had an impact on the sequence of events and of areas whose conditions must be preserved to evaluate the event (quarantined equipment and areas). The licensee will ensure that the equipment and areas identined on this list are not disturbed prior to release by the IIT. In this regard, work in progress or planned on this equipment or in these areas will be held in abeyance so that evidence of the equipment's functioning durin; the incident and the areas' conditions will not be disturbed. Personnel access to areas and equipment subject to this quarantine will be minimized, consistent with plant safety.
The licensee is responsible for quarantined equipment and areas and can take action involving the equipment and areas it deems necessary to: (1) achieve or maintain safe plant conditions, (2) prevent further equipment degradation, or (3) test or inspect as required by foe plant's Technical Specifications. To the maximum degree possible, these actions should be coordinated with the IIT leader in advance or notification made as soon as practical. The IIT leader may authorize a release, in whole or in part, of those areas or equipment subject to the quarantine upon a determination that the llT has received sufficient information i
concerning the areas or equipment requested to be released, or to permit necessary troubleshooting of the equipment, required testing or maintenance to be performed.
l 1-12 l
l
T Exhibit 1-1 (continutd) 2-(3)
All records will be preserved intact that may be related to the event and any surrounding circumstances that could assist in understanding the event. Such records shall be retained for at least tro years following the event whether or not required to be retained by regulation or license condition.
(4 The licensee will make available to the IIT for questioning such individuals employed by the licensee or its consultants and contractors with knowledge of the event or its causes as the llT deems necessary for its investigation.
(5)
The licensee will ensure that any investigation to be conducted by the licensee or a third party will not interfere with the IIT investigation. The licensee will advise the IIT of any investigation to be conducted by the licensee or a third party.
Reports of such investigation will be promptly provided to the IIT.
Issuance of this confirmatory action letter does not preclude the issuance of an order formalizing your commitments. The above commitments may be relaxed for good cause. -
If your understanding differs from that set forth above, please call me immediately.
Sincerely, (Name]
Regional Administrator cc: IIT Leader l
NRC Office Directors Regional Administrators l
l-i i
1-13
Exhibit 1-2 i
Generic Order hiodifying License UNITED STATES i
NUCLEAR REGULATORY COhihilSSION In the hiatter of
)
)
(LICENSEE)
)
Docket No.
)
License No.
__Eacility Natacl_
)
l
)
EA i
ORDER hiODIFYING LICENSE (EFFECTIVE lhihiEDIATELY) 1.
Wame_of licensee) (Licensee) is the holder of Facility Operating License No.
[or appropriate reference for materials licensee] issued by the Nuclear Regulatory Commission (NRC or Commission) pursuant to 10 CFR Part 50 [or appropriate regulations for material licensee] on
. The License authorizes the operation of
_ (facility) in accordance with conditions specified therein. The facility is located on the Licensee's site in II.
The NRC Executive Director for Operations has established an Incident Investigation Team (IIT) to investigate the circumstances surrounding an incident. IDescribe incident) An llT was established because [ describe in one or two senlences the signincance of the eventl. The purpose of the '.nvestigation is to obtain necessary information to assure sufficient understanding of the cause of the event so that a deterrrination may be made as to what corrective actions will be suf6cient to provide reasonable assurance that operation of the facility will not create an undue risk to the public health and safety, iDescribe facts which will form the bases for the Order. Sufficient facts should be described in this Section to permit the development of a iustificaticn in the next Section to support each of the actions to be ordered.]
l-14
111.
Mhis section should provide _the iustification for issuing the Order. in light of the facts described in Section 11.) Consequently, I lack the requisite reasonable assumnce that (1) the Licensee's current operations can be conducted under License No.
in compliance with the Commission's requirements, (2) the Licensee will cooperate with the NRC in the conduct of its IIT investigation, and (3) the health and safety of the public, including the Licensee's employees, will tie protected. Therefore, the pubiic health, safety, and interest require that License No.
be suspended. Furthermore, pursuant to 10 CFR 2.202, I find that public health, safety, and interest require that this Order be immediately effective.
IV.
Accordingly, pursuant to Sections 103 Louppropriate section for materials licensee),161b, 161c,161i,182 and 186 of the Atomic Energy Act of 1954, as amended, and the Commission's regulations in 10 CFR 2.202 and 10 CFR Part 50 for other appropriate regulationsl, IT IS IIEREllY ORDERED, EFFECTIVE IMMEDIATELY, TilAT LICENSE NO.
IS MODIFIED AS FOLLOWS:
A. The Licensee shall maintain the facility in cold shutdowr Sr other appropriate mode description] until the Regional Administrator determines snat there is a sufficient understanding of the causes and consequences of the incident and sufficient corrective action has been taken such that resumption of operations poses no undue risk to public health and safety;
- 13. The Licensee will resure that the equipment and areas involved in the incident are not disturbed prior to release by the llT. In this regard, the Licensee shall hold in abeyance any work in progress or planned on equipment that failed or malfunctioned during the event and equipment and areas that had an impact on the sequence _of events so that evidence of the equipment's functioning nd the areas' conditions during the incident will not be disturbed. The Licensee shall minimize, consistent with plant safety, personnel access to areas and equipment r.ibject to this quarantine. The Licensee is responsible for quarantined equipment and arvas and can take action involving the equipment and areas it deems necessary to: (1) achieve or maintain safe plant conditions, (2) prevent further equipment degradation, or (3) test or inspect as required by the plant's Technical Specifications. To the maximum degree possible, these actions should be coordinated with the llT leader in advance or notification made as soon as practical. The IIT leader may authorize a release, in whole or in part, of those areas or equipment subject to the quarantine upon a determination that the llT has received sufficient information concerning the areas or equipment requested to be released, or to permit necessary troubleshooting, testing or maintenance, of the equipment.
l-15 l
C. The Licensee shall preserve intact all records that may be related to the event and any surrounding circumstances which could assist in understanding the event. Such records shall be retained for at least two years following the event; D. The Licensee shall make availabic to the IIT for questioning such individuals employed by the Licensee or its consultants and contractors with knowledge of the event, its causes, or consequences as the llT deems necessary for its investigation; E. The Licensee shall ensure that any investigation to be conducted by the Licensee or a th id party will not interfere with the llT investigation. The Licensee shall advise the llT of any investigation to be conducted by the Licensee or a third party. Reports of such investigation shall be promptly provided to the llT.
~
The Regional Administrator, Region _, may, in writing, relax or rescind this Order upon demonstration by the Licensec of good cause.
V.
In accordance with 10 CFR 2.202, the Licensee must, and any other person adversely affected by this Order may, submit an answer to this Order, and may request a hearing of this Order, within 20 days of this Order. The answer may consent to this Order. Unless the answer consents to this Order, the answer shall, in writing and under oath or afGrmation, specincally admit or deny each allegation or change made in this Order and shall set forth the matters of fact and law on which the Licensee or other person adversely affected relies and the reasons as to why the Order should not have been issued. Any answer filed within 20 days of the date of this Order may include a request for a hearing. Any answer or request for a hearing shall be submitted to the Secretary, U.S. Nuclear Regulatory Commission, ATrN: Chief, Docketing and Service Section, Washington, DC 20555. Copies of the hearing request also shall be sent to the Director, OfGee of Enforcement, U.S. Nuclear Regulatory Commission, Washington, DC 20555, to the Assistant General Counsel for Hearings and Enforcement at the same address, to the Regional Administrator, NRC Region _, (regional addmu), and to the Licensee if the answer or hearing request is by a person other than the Licensee. If a person other than the Licensee requests a hearing, that person shall set forth with particularity the manner in which his interest is adversely affected by this Order and shall address the criteria set forth in 10 CFR 2.714(d).
If a hearing is requested by the Licensee or a person whose interest is adversely affected, the Commission will issue an Order designating the time and place of any hearing. If a hearing is held, the issue to be ensidered at such hearing shall be whether this Order should be sustained.
1-16
J
)
Pursuant to 10 CFR 2.202(c) (2) (i), the Licensee may, in addition to demanding a hearing, at the time the answer is Sled or sooner, move the Commission to set aside the immediate i
effectiveness of the Order on the ground that the Order, including the need for immediate effecti : ness, is not based on adequate evidence but on mere suspicion, unfounded allegations, or error, i
In the absence of any request for hearing, the provisions specined in Section IV above shall be final 20 days from the date of this Order without further order or proceedings. AN i
ANSWER OR A REQUEST FOR liEARING SIIALL NOT STAY TliH lhih1EDIATE EFFECTIVENESS OF TlilS ORDER.
4 i
i I
4 l
FOR Tile NUCLEAR REGULATORY COhihilSSION Deputy Executive Director for Nuclear Reactor Regulation, Regional Operations, and Research l
l l
l Dated at Rockville, hiaryland I
this _ day of
,19 (XX) i l
\\
1-17 l
l
~
~. -.. - -
Exhibit 1-3 Background Ir. formation (compiled by the Region) for the IIT Briefine Packagg Prior to the IIT's arrival, the Region prepares a briefing package to c.;uaint team members with the unique aspects of the plant design and data related to the event. This package may contain the following information:
Preliminary Sequence of Events Confirmatory Action Letter and/or Order
- Licensee Post-Trip Review
- Control Room Operator Logs Computer Alarm Printout / Strip Chart Recordings
- Applicable Licensee Procedures Applicable Licensee Technical Specification Requirements Preliminary Notification
- Licensee Press Release
- NRC Press Release
- Licensee Organization Chart
- Diagram of Facility Layout Applicable Piping and Instrumentation Drawings
- Applicable Vend 0r Drawings and Manuals
- SALP Reports
- Applicable inspection Reports
- Applicable Licensee Event Reports v Applicable Maintenance Logs
- Applicable Electrical Logic Diagrams i
Preliminary Operator Written Statements e
1 18
l
]
i Exhibit 1-4 j
Example EDO hiemorandum to the Commission i
j
[date) 1 h1Ehf 0RANDUhi FOR:
Chairman [Name)
Commissioner [Name]
j Commissioner [Name) i l
Commissioner [Name]
l Commissioner [Name)
]
i FROht:
[Name) i Executive Director for Operations SUIUECT:
INVESTIGATION OF THE [DATE] EVENT AT [NAh1E]
NUCLEAR POWER PLANT, INVOLVING LOSS OF I
OFFSITE POWER AND FAILURE OF ONSITE POWER ON 1
DEhfAND AT UNIT 1 i
i On [date) at 9:58 a.m. EST, the licensee for the [Name] Nuclear Power Plant notified the NRC that they had declared a Site Area Emergency for Unit I due to a loss of offsite power concurrent with a loss of onsite emergency diesel generator (EDG) capability. The loss of offsite power was caused by a truck accident in the switchyard. At the time of the incident i
Unit I was in cold shutdown with the B reserve auxiliary transformer and the B EDG out of l
service for maintenance. The A EDG started as designed but immediately tripped. Thirty six minutes into the event, the A EDG was manually started, at which time core cooling was i
reestablished to Unit 1. The Unit I reactor coolant temperature peaked at 136 degrees Fahrenheit and stabilized at 100 F after emergency ac power was restored. The licensee downgraded the event to an Alert at 10:15 a.m. EST based on the restoration of onsite power.
l Unit 2 reactor also tripped from 100 percent power as a result of the truck accident, but did not lose offsite power. At 11:29 a.m. EST the B reserve auxiliary transformer was re-energized, restoring neimal power to the engineered safeguards buses.
An Augmented Inspection Team (AIT) was immediately sent to the site by Region 11 to investigate the event. However, because of the safety significance and the potential regulatory questions the event raises, I have requested AEOD to take the necessary actions to upgrade the current AIT to a seven member NRC Incident Investigation Team (IIT). Arrangements are being i cde under the provisions of a hiemorandum of Agreement with the Institute of Nuclear Power Operations for industry participation. The team is to: (a) fact find as to what happened; (b) identify the probable cause as to why it happened; and (c) make appropriate findings and conclusions which would form the basis for any necessary follow-on actions.
t l-19 l
Exhibit 14 (continued)
The Commissioners 2-The team will report directly to me and is comprised of: [name), (RV) IIT Leader; [name],
(NRR); [name], (AEOD); [name), (AEOD); [name], (NRR); [name), (NRR); and (name],
(RI). All team members are relieved of all normal duties while assigned to the llT. Enclosed is the charter for the llT to use in the review of the event.
The IIT was selected on the ba,is of their knowledge and experience in the fields of reactor systems, reactor operations, human factors, and power distribution systems. Team members have no direct involvement with [ Plant Name]. The additional team members and IIT leader are currently enroute to the site.
The licensee has agreed to preserve the equipment in accordance with the Confirmatory Action Letter which was issued by the Regional Administrator on [date). The licensee has also agreed not to take [ Plant Name] critical until concurrence is received from the NRC.
The IIT report will constitute the single NRC fact finding investigation report. It is expected that the team report will be issued within 45 days from now.
[Name]
Executive Director for Operations cc: SECY OGC ACRS OPA Regional Administrators i
1-20
fahibit 1-4 (contimted)
Enclosure incident Investigation Team Charter Loss of Offsite power and Failure of Onsite power on Demand at [ plaint Name].
The scope of the !!T investigation should include conditions preceding the event, event chronology, systems response, human factors considerations, equipment performance, precursors to the event, emergency response (NRC and licensee), safety significance, radiological considerations, and whether the regulatory process and activities preceding the event contributed to it. Within the framework of this scope the IIT should specifically:
(1)
With respect to conditions preceding the evsnt Evalt. ate the activities and plans which established the initial plant conditions. Identify the initial plant conditions (prior to start of the transient). Identify whether the conditions were prudent and proper. Facts should be obtained regarding the licensee's actions associated with providing assurance of adequate RHR cooling during the outage activities, including planning and coordination of equipment outages, emergency responses to mid loop operational events, and review of applicable NRC generic communications. Identify any procedural requirements and/or deficiencies asso-clated with the fuel truck's movement in the protected area.
(2)
With respect to event chronologyl Develop and validate a detailed sequence of events associated with the loss of all AC power transient on Unit 1. Establish the cause of the Unit 2 trip.
(3)
Willtresoect to emergency response: Develop and validate a detailed sequence of events associated with implementation of the emergency plan implementing procedures, including problems associated with the ENN and ERF computer.
(4)
With respect to systems resoonse: Evaluate the response of the 1 A EDG, including equipment performance (blackout sequencer and jacket water pres-sure). Determine whether the Unit I switchyard breaker actuations were appropriate and expected.
(5)
With respect to human factors considerations: Evaluate personnel performance including local operator actions in response to the 1 A EDG failure to start.
With respect to safety significance of the event: Evaluate the potential for long term core damage due to this transient, include the responses of operations and maintenance personnel, RCS heatup, and potential containment challenges.
Evaluate the potential for a truck fuel conflagration in this scenario and whether fitness for duty nile was complied with.
1-21
Rhibit 1-4 (egnlinned) gfypt 3,9h (6)
Wittuc3pect to the regulatory process and activities preceding the event:
Evaluate the adequacy of plant Technical Specifications for safety system oper-ability / availability during refueling mode and any implications to other modes.
The scope of the investigation does not include: 1) assessing violations of NRC rules and requirements; 2) reviewing the design and licensing bases for the facility, except as necessary to assess the cause for the event under investigation; 3) assessing reasonable assurance of offsite emergency response capabilities of State and local agencies; and 4) determining resumption of licensed operations.
O l-22
Exhibit 1-5 NRC Region 1 Mobile Nondestructive Evaluation Laboratory The NRC Mobile Nondestructive 12boratory is a fully equipped trailer capable of performing a broad spectrum of analyses, it is manned by a qualified NDE Level 111 NRC inspector and two technicians also qualified to at least lxvel 11 in the basic NDE techniques of radiography, ultrasonic, magnetic particle and liquid penetrant testing. The NRC inspectors are qualified weld inspectors. They are supplemented by two contractor personnel who are also qualified to the basic techniques of NDE and also provide the radiographic sources.
The NDE crew cn be dispatched to the site without the trailer if consultation is needed or only limited inspection equipment is required for the test. The routine inspections performed by the NDE Mobile Laboratory include pre-service and inservice inspection, modification installation and fabrication, as built configuration verification of piping systems and mechanical components, and weld qualification and process control. Listed below are the inspection capabilities of the Region i NDE Mobile Labuatory:
(1)
Radiography The laboratory is equipped with complete dark room facilities, isotope storage area, and facilities to perform and interpret radiographic examination of licensee inspection procedures or applicable codes, specifications and standards.
(2)
Ultrasonic The laboratory has six (6) ultrasonic units. These instruments are portable battery-operated capable of performing manual examination of welded components at a nuclear facility (with accessories).
(3)
Thickness Gauge Portable battery-operated instrument, digital readout and automatic data logging for measuring metal thicknesses within the range of.050" to 10".
(4)
Liquid Penetrant Equipment to perform visible solvent removable and florescent penetrant testing.
(5)
Magnetic Particle Equipment to perform (ac) yoke and (de) prod magnetic particle examination.
1-23
Exhibit 1-5 (continued)
(6) lhidness Portable battery-operated instrument for measuring hardness of material which can then be converted to Brinell or Rockwell standards and approximate tensile strength.
(7)
Cable TraccI Portable, battery-operated instrument for locating and tracing electrical cables.
(8)
Digital Heat Probe Portable, batterj-eperated instrument for reading temperatures during welding, post weld heat treat, etc.
(9)
Digital Multimeter Portable, battery-operated instrument for measuring volts, ohms, and amps of f
electronic circuits.
(10)
AMP Pmbclil Instrument used for checking line voltage and amperage, i.e., welding and magnetic particle currents.
(11)
Shore Duromelet Used to check hardness of rubber products.
(12)
Digital Hand Torque Wrench Digital readout hand torque wrench for static torque measurements with accuracy and readability. A large LED digital display along with digital peak memory to make static torque measurements.
(13)
Windsor Probe iSwiss Hammer)
Used to determine the compressive strength of concrete.
(14)
Infrared Thermometer Used for remote observation of materials temperature.
1-24
1 l
l Exhibit 1-5 (continued) i l
l (15)
Surface Comparators Used to determine average surface finish of metals.
(16)
Megger - OHhtS Generator l
Hand-cranked unit for measuring ohms resistance ofitems.
(17)
Ferrite Indicator (Severn Gauge)
A device used for indicating the ferrite content of austenitic stainless steel weld metals.
(18)
Nortec-Eddy Current hiachine Portable, battery-operated unit used for measuring paint thickness defects.
(19)
R. hieter t
Portable, battery-operated instrument for locating rebar embedded in concrete.
(20)
RPM Photo Tachometer Portable, battery-operated instrument used remotely, to determine motor RPMs, such as pump shaft speed.
(21)
Vibration Melst Portable, battery-operated instrument for measuring acceleration, velocity, and displacement of motors.
(22)
EiherscoPe i
Instrument used to examine remote and hard to get to areas, such as inside pipe -
surface.
(23)
Surface Indicator Portable, battery-operated instrument used to measure surface finishes of machined materials.
i 1-25
1 Exhibit 1-5 (continued)
(24)
Allov Analyzer Portable, battery-operated instrument designed for rapid non-destructive onsite verification of type and eleme'it composition of many different engineering alloys.
1 (25)
Dimensional Aids vernier calipers forma-gauge e
slope angle indicators various coating thickness measuring devices O
1-26
O Exhibit 1-6
(
Agreement on Waiver of Compensation. Conflicts of Interest and Release of Investigation Information for Industry Representatives Participating in Incident Investigation Teams (llTs)
I understand that NRC has solicited the participation of industry in connection with its incident investigation of [Name of FacilityJ. I have been requested by my employer [Name of employerl to participate in NRC's llT investigation of such incident. I understand that my personal participation has been requested by my employer and not at the specific request of the federal government. I intend to offer the NRC team leader my best effort concerning such aspects of the investigation as I may participate in, but that I am under no obligation to the federal government to do so.
I agree that any services which I render to or for the benefit of the government, pursuant to the agreement between NRC and INPO concerning 11Ts, shall be gratuitous, and I waive any claim for payment or compensation from the Government of any kind. I understand that I will not be an employee of the government as a result of any service which I may render under the auspices of the agreement between NRC and INPO.
I agree that I will abide by the guidelines and procedures established for the aperation of IITs, including the guidelines for handling differences of opinion and release ofinvestigation information. I understand that my input to the IIT will be subject to review by other team members and the IIT leader, and that differences of opinion will either be resolved or documented in an appendix to the IIT report. I understand that the team leader is to decide on the release of investigation information to parties outside the team.
With respect to proprietary and potentially proprietary information that is disclosed to me in connection with my participation in any llT, I agree:
not to make further disclosures e
not to make further copies to return my copies to the team leader or otherwise dispose of them as directed by the team leader upon completion of the investigation not to make further disclosures of copies of investigation or other notes o
that cocain potentially proprietary information to report to the NRC llT leader any uses of information which do not comply with this statement n/
l-27 I
l
Exhibit 1-6 (continued) to consult with the team leader before taking any action if I have any doubt or question as to whether it would be in accordance with this agreement Aithough I am not acting as a government employee or a special government employee or as a government contractor in my participation with the llT, I understand the importance of NRC avoiding the appearance of con 0ict of interest in connection with my participation with the llT. Accordingly, with respect to con 0icts of interest, I make the following representations:
(Check one statement under each number) 1.
()
Neither I nor any member of my household has had direct j
previous involvement with the facility that I will be reviewing.
()
I or a member of my household has had direct previous involvement with the facility that I will be reviewing. If you checked this statement, please explain.
O 2.
()
Neither I nor any member of my household is now or has previously been an employee or contractor of the licensee or has otherwise received compensation from the licensee.
()
I or a member of my household is now or has previously been an employee or contractor of the licensee or has otherwise received compensation from the licensee. If you checked this statement, please explain.
1-28
Exhibit 16 (continued) 3.
()
Neither I nor any member of my household is now or has previously been an owner, partner, trustee, officer ar director of the licensee.
()
I or a member of my household is now or has previously been an owner, partner, trustee, officer or director of the licensee. If you checked this statement, please explain.
3 4
()
Neither I nor any member of my household has a. y arrangement for, or is negotiating for, future employment by the licensee or for any future financial or official relationship with the licensee.
()
1 T ano'her member of my household has an arrangement for, or is negotiating for, future employment by the licensee or for a future financial or official relationship with the licensee. If you i
checked this statement, please explain.
5.
()
Neither I nor any other member of my household owns or controls stock, bonds, or other security interests of the licensee.
()
I or another member of my household owns or controls stock, bonds, or other security interests of the licensee. If you checked this statement, please explain. Your explanation should include the current market value of the securities.
O l-29
Exhibit 1-6 (contiayed) 6.
(:
To my knowledge, I do not have any relative who is employed by the licensee in a management capacity.
()
I have a relative who is employed by the licensee in a raanagement capacity. If you checked this statement, please explain.
7.
()
To my knowledge, the licensee is not owned or controlled by, and does not own or control, any entity of which I am currently an employee, contractor, owner, partner, trustee, officer or director.
()
The licensee is owned or controlled by, or owns or controls, an entity of which I am currently an employee, contractor, owner, partner, trustee, officer or director, if you checked this statement, please explain, i
In the above statements, the term " licensee" means the licensee, the architect-engineer or the nuclear steam supply system vendor of the facility where the incident under investigation has taken place In the event that a potential for a conflict of interest develops during the course of this incident investigation, I will immediately report all relevant information to the incident investigation team leader.
Name (please print)
Signature Date 1-30
Exhibit 1-7 i
EDO Memorandum on Waiver of Commission Policy on l
Avoidance of Organizational Conflicts of Interest for Industry Particio; mis MEMORANDUM FOR:
Chairman [Name]
Commissioner (Name]
Commissioner [Name]
Commissioner (Name]
FROM:
[Name]
l Executive Director for Operations SUWLt.
WAIVER OF COMMISSION POLICY ON AVOIDANCE OF ORGANIZATIONAL CONFLICTS OF INTEREST FOR IN-DUSTRY PARTICIPANTS ON [ FACILITY] INCIDENT INVESTIGATION TEAM It is,
e Nuclear Regulatory Commission (NRC), in accordance with Section 170A w _,.mnic Energy Act, to avoid organizational conflicts of interest. Consequently, p
the NRC normally would not enter into a relationship where one of the participants would be Q
placed in a position where its judgment might be biased or where it might receive an unfair competitive advantage. This policy may be waived, however, in situations where the work cannot be performed except by a party whose interests give rise to a question of conflict of interest and where administrative and/or technical controls can be employed by the NRC to neutralize the conflict.
l The NRC has decided to solicit the participation of IName(s) of industry nersonnel and l
affiliated organization] on [Name of facilityl NRC Incident Investigation Teams (IIT). INPO l
acts as contact with NRC to nominate an industry representative. The objective of the IIT is to perform a thorough factual investigation of significant operatianal events at NRC licensed facilities and to collect, analyze, and document factual information and evidence sufficient to determine the probable causes of these events. The reasons for soliciting industry participation on the [Name of faci;itvl IIT is to obtain an independent point of view on technical issues, Nd to facilitate the feedback of information to the industry for the self-initiation of por.ntial preventative and/or corrective measures. The outcome of any given IIT could possibl have a direct impact on preventative and/or corrective measures recommended 3
to or imposed upon the industry by the NRC. The participation of. industry personnel in an IIT would normally be precluded under the Commission's policy because of the potential self-interest of the industry in the outcome of an IIT. The NRC believes, however, t' at the participation of industry representatives is esser "-' to achieve the objectives for which the.
participation is solicited and to the accomplishr-cf the overall goals of the Incident -
O Investigation Program.
1-31
. ~
Exhibit 1-7 (continued)
The Commissioners A number of controls have been established to preclude the introduction of bias into any incident investigation and to assure protection of the government's interest. Industry participants will be carefully screened to avoid any possibility of personal conflicts of interest resulting from such things as financial interest in the owner of the facility being investigated, previous involvement in the design or operation of the facility being investigated, and the like.
Also, the technical product of the industry participants will be subject to review and criticism by other members of the team, including the IIT leader, as well as by NRC management.
The Director, AEOD has recommended that the Commission's Policy on Avoidance of Organizational Con 0icts of Interest be waived to avoid any questions that might arise under that policy concerning the participation of industry representative (s) on the IName of facilitvl IIT. Such a waiver documents the fact that NRC management has made a conscious decision in balancing the risks of allegations of biased input into the IIT against the benefits from industry participation. Based on the foregoing and after consultation with the Office of General Counsel, I make the following determinations:
The activities to be performed by the IIT are vital to the NRC mission.
The participation of industry personnel on the IIT is essential to achieve the objectives for which that participation is solicited and to the success of the overall goals of the Incident Investigation Program.
Technical and administrative controls will be employed to neutralize the conflict of interest posed by the participation of industry personnel on the team.
lt is in the best interest of the United States to waive the Commission's Policy on Avoidance of Organizational Conflicts of Interest.
Pursrint to the waiver provision specified in 41 CFR 20-1.54, " Contractor Organizational Conthets of Interest," the Commission's Policy on Avoidance Organizational Conflicts of Interest is hereby waived for the purposes of allowing the participation of IName(s) of industry personnel and affiliated oreani7ation1 on the IName of facilityl NRC Incident Investigation Team and for IName effmployerl with respect to such participation by [Name of industry participan0
[Name]
Executive Director for Operations O
1-32
Exhibit 1-8 Region Action item Checklist For Activating an llT ACTION 1.
Consult with the Directors of NRR or NMSS and AEOD to consider whether an llT is appropriate.
2.
Make recommendation to EDO.
3.
Issue Confirmatory Action letter (CAL).
4.
Designate a regional representative to interface with the IIT.
5.
Prepare briefing package and an event bdefing to give the team upon site arrival. Include a discussion of related systems and processes in the briefing. (Exhibit 1-3)
=
6.
Confer with OPA, Headquarters about the need for a Public Affairs Officer onsite.
7.
Negotiate with the licensee for sufficient office space for the llT.
A conference room and work space for the team (preferably onsite)
At least 2 interview rooms Telephones (including conference call)
Area for administrative functions Office spa:e for IIT leader Area for reviewing transcripts 8.
Provide secretarial support.
9.
Arrange for site access for the IIT.
10.
Coordinate the entrance meeting and site tour, 11.
Provide staff to monitor troubleshooting.
s 1-33
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/~'N GUIDELINE 2: CONDUCTING AN INCIDENT INVESTIGATION
(
v 2.1 hrpRK Guideline 2 provides guidance for conducting an Incident Investigation Team (IIT) investigation.
2.2 Background
The objectives of the llT are to: (1) conduct a timely, thorough, syster .ic, and independent investigation of safety-significant events that occur at facilities licensed NRC; (2) collect, analyze, and document the factual information and evidence sufficient Jetermine the probable causes, conditions, and circumstances pertaining to those events; and (3) determine whether the agency actions taken prior to the event contributed to the cause or course c f the event.
To meet these objectives, the investigation includes four major activities: (1) collection of data and information; (2) analysis and integration of the facts; (3) determination of findings and conclusions; and (4) preparation and presentation of the team's report.
These guidelines are intended to assist the investigation rather than limit the initiative and (3
good judgment of the IIT leader or members; they should use their experience and those
(,)
techniques that provide the most confidence in assuring that IIT objectives are achieved.
A detailed team chser delineating the scope of the investigation will be provided to the IIT leader. Further de.ils on the investigation scope are provided in Section 1.5 of Guideline 1.
l 2.3 IIT I eader 3<estonsibilitin I
The IIT leader manages the investigation and delegates responsibilities to NRC team l
members and to assigned Office for Analysis and Evaluation of Operational Data (AEOD) staff. Checklists.for conducting the investigation are provided in Exhibit 2-1. Specific responsibilities 12clude:
(1)
Directir and managing the IIT in its investigation and assuring that the objective and l
schedule.<gare met for the investigation, as defined in NRC Management Directivr 8.3.
l (2)
Identifyis, adding and removing equipment from the quarantined eqaipment list (QEL) within the constraints of ensuring plant safety and determining causes for l
equipment anomalies (see Guideline 4).
i
)
\\
s l
(3)
Serving as principal spokesperson for the IIT and the point of contact for interaction with the licensee, NRC of5ces, Advisory Committee on Reactor Safeguards (ACRS),
l Advisory Committee on Nuclear Waste (ACNW), news media, and other organizations on matters involving the investigation.
(4)
Coordinating activities with the Director, AEOD, as necessary, to obtain ad-ministrative support and/or advice and consultation on procedural matters involving the investigation.
(5)
Preparing preliminary notification (PNs) and other status reports documenting IIT activities, plans, significant findings, and safety concerns that may require prompt NRC action, e.g., issuance of Information Notices, Bulletins, or Orders.
(6)
Organizing IIT work, including the establishment of schedules, plans, work tasks, daily team meetings, etc. Holding daily taam meetings to review progress and exchange ideas and findings.
(7)
Assigning tasks to NRC team members in accordance with their knowledge, ex-perience, and capabilities, The IIT leader may select and assign duties to an assistant team leader, as appropriate. The IIT leader will identify assignments for the industry representative team member (s).
(8)
Not permitting NRC team members to dilute their investigative commitments with any other work assignments: their sole work activity should be limited to the incident investigation until the report is published.
(9)
Administering resources provided and obtaining resources needed to properly carry out all necessary investigative tasks (e.g., obtaining additional team members, consultants, contractor assistance).
(10)
Ensuring that investigative activities do not unnecessarily interfere with plant activities.
(11)
Initiating requests for information, witnesses, technical specialists, laboratory tests, and administrative support.
(12)
Controlling proprietary, safeguards and other sensitive information to personnel with a "need to know" who possess an appropriate security clearance.
(13)
Handling communications with NRC headquarters and regional officials (designated representative).
(14)
Informing the Executive Director for Operations (EDO), through the Director, AEOD, of all significant findings, developments, and investigative progress. Request 2-2
l that the EDO grant an appropriate extension of time if established deadlines cannot be met.
w (15)
Consu! ting frequently with IIT members individually and via daily team meetings to ensure a team approach to the investigation in matters such as revising the report outline, assigning member responsibilities, discussing the list of items that should be closed out before leaving the site, identifying investigatory milestones, and seeking consensus on the contents and relevant information to include in status and final reports.
(16)
Ensuring, in cooperation with the team membeis and the technical writer / editor, the completion of the final report within the due date established by the EDO.
(17)
Ensuring that frequent and successful communications occur among the AIT, IIT, and the licensee during the conversion to ensure an orderly transition in the event that the investigation is either upgraded or dowr. graded (See Guideline 1).
(18)
Ensuring that the following activities are completed prior to the end of the onsite portion of the investigation:
a plant tour and thorough inspection of affected equipment, all onsite interviews (may need to be continued in a second onsite visit),
p b
development of a detailed sequence of events, review and approval of the quarantined equipment list and corresponding o
troubleshooting action plans (TAPS), and arrangements with regional personnel for the monitoring of component troubleshooting activities.
(19)
As requested, briefing the Director, NRR (or as appropriate, the Director, NMSS) and the Regional Administrator on the facts surrounding the event, in support of decisionmaking to authorize the affected licensee to resume facility operations.
(20)
Promptly conveying and documenting significant ancillary findings or information outside the scope of the IIT charter to regional management for followup action.
(21)
Conducting a team meeting after report issuance to formulate proposed staff actions to address report findings.
(22)
Ensuring that a " lessons learned" review meeting is conducted with team members to permit a team evaluation of the IIT effort.
O) tV 2-3
i 2.4 Role of the Recion in Suonort of the Conduct of the irrident Investigation The responsibilities of the Region during the conduct of an IIT investigation are to: (1) assist in briefing and providing background information, including that related to associated systems and processes, to the 11T when it arrives onsite, (2) provide onsite support for the IIT, and (3) identify and provide staff to monitor licensee troubleshooting activities to assess equipment performance. The Regional Administrator should designate a regional representative to interface with the HT The regional representative should attend most meetings between the IIT and the licensee. The responsibilities of the Region during IIT activation are provided in Guideline 1, Section 1.8.
2.5 Initial Actions by the IIT Leader (1)
Prior to arriving onsite, the IIT leader should introduce the team members and brief the team on the event, on the scope of the investigation, and on how the team will function. In addition, the IIT leader should verify that all industry representatives have signed a statement (Exhibit 1-6 of Guideline 1) regarding their participation in the IIT During this briefing, the IIT leader should assign each team member a specific area of responsibility based on individual expertise, e.g., compiling the sequence of events, examining equipment performance, determining the human factors issues.
(2)
Upon arriving at the site, the IIT leader should give priority attention to: (a) initiating a meeting with the licensee to learn what is known about the event and to reach an understanding with the licensee about the IIT's activities; (b) scheduling interviews with personnel having a direct knowledge of the event; (c) developing a detailed sequence of events; (d) compiling a QEL and TAPS; and (e) responding to press inquiries. Guidance for conducting press releases is contained in Exhibit 2-2.
(3)
The IIT leader should ensure that arrangements have been made for those items l
requiring licensee assistance. These could include:
scheduling an entrance mceting with licensee management as soon as o
practical to discuss the event and the IIT investigation, obtaining stenographers, if possible, to transcribe the entrance meeting and, in order to facilitate this, arranging for a meeting location in l
advance.
scheduling a tour of the plant to begin immediately after the entrance meeting to inspect the affected systems and equipment and to gain familiarity with the plant.
l l
2-4 l
l l
requesting the licensee to provide photographic services during the O
investigation.
identifying individuals with personal knowledge of the event and establishing a preliminary schedule for interviews.
reviewing the preliminary list (compiled by the licensee) of all failed equipment and any equipment suspected of performing abnormally during the event; this list constitutes the initial QEL to be discussed during the entrance meeting.
(4)
AEOD staff will accompany and provide technical and administrative support to the IIT. The IIT leader should ensure that the admmistrative coordinator has verified the extent of administrative support provided by the Region, e.g., background documents, secretarial support, regional liaison. Suen support could include:
providing a briefing package for the team (see Guideline 1, Exhibit 1-3).
obtaining office space for llT members.
obtaining a meeting room to conduct IIT meetings and daily business.
O e
obtaining an area for administrative functions.
identifying and distributing telephone numbers and site locations to establish communications for the IIT.
confirming that the room (s) for conducting personnel interviews are e
available as previously requested by AEOD.
obtaining unescorted access to the protected area for IIT personnel, however, if time does not permit the completion of training for unescorted access, the llT leader should arrange to obtain escorted access.
2.6 Entrance Meeting with the Licensee The objectives of the entrance meeting are to: (1) establish a rapport with and enlist the cooperation of the licensee, (2) discuss the purpose and scope of the IIT investigation, (3) obtain the licensee's understanding of what occurred and why it occurred, and (4) request assistance from the licensee in obtaining information and resources. The following activities take place during the entrance meeting:
v 2-5
(1)
The llT leader v/ill be the lead spokesperson for the NRC and will be responsible for directing the meeting and ensuring that all the major objectives of the meeting are covered.
4 (2)
The stenographers must receive accurate information regarding the names of those speaking, their job titles, and their employers.
(3)
An attendance sheet should be circulated among those present at the meet:
(4)
The IIT leader should make an opening statement similar to the following:
The purposes of the incident investigation are to establish what happened, to identify the probable causes, and to document our findings and conclusions and issue a report within about 45 days. We will also be issuing status reports to our headquarters to keep them informed on the progress of our investigation.
The investigation is not a reanalysis of the plant design, nor is it a compliance inspection, although our report can be used to form the basis for enforcement actions. We request that any information available as a result of your or other investigations be shared with us.
There are several things we would like to accomplish at this meeting. First, we want to get up to speed on your understanding of what occurred and your hypothesis of why it occurred. Second, we would like to establish our interfaces for the investigation where we can seek technical information or ask for assistance such as escorts or looking at any particular pieces of technical documentation or equipment involved in the event. Finally, we would like to review with you our investigation process which includes interviews, the troubleshooting of quarantined equipment, the handling of press ingmries, and the exchanging of information between your staff and the team. That is our agenda for this meeting.
(5)
Licensee personnel should be allowed to describe that happened with few interruptions. The team should then identify additional personnel for interviews and followup topics to evaluate.
(6)
The IIT leader should request that the licensee post a notice on all plant bulletin boards and major points of ingress and egress describing the purpose of the IIT inves-tigation and soliciting mformation regarding the event (Exhibit 2-3). This posting should also be made at any offsite locations that might ce involved in the incident.
(7)
The IIT leader should review with the licensee the preliminary list of failed equipment, equipment suspected of performing abnormally during the event, and areas whose conditions need to be preserved. This list constitutes the initial quarantined equipment list (QEL). The QEL should be maintained by the licensee 2-6
4 O
and be as current and complete as possible and should generally include only equipment significantly involved in the event that failed to perform its intended l
function including areas that may need to be quarantined.
(8)
The IIT leader should confirm with the licensee that equipment on the QEL will be clearly identified and secured, and that no maintenance / testing will be initiated until the action plan for each component is reviewed and approved by the team. The IIT leader should indicate that the licensee can take any action involving the QEL necessary to: achieve or maintain safe plant conditions, prevent further equipment degradation, or conduct testing or inspection activities required by the plant's Technical Specifications. To the degree possible, these actions should be coordinated 1
1 with the IIT leader in advance or notification made as soon as practical afterward.
(9)
The llT leader should request that the licensee provide a preliminary sequence of events and update it as additional information and data become available.
(10)
The IIT should review with the licensee all aspects of the IIT investigation process, including interviews, the troubleshooting of quarantined equipment, the handling of press inquiries, and the exchange of information between the IIT and the licensee.
1 (11)
The IIT should request that copies of all documents requested by the team (e.g., the computer sequence of events or data logging, relevant procedures, operating instructions, detailed plant design information) be sent to a designated receiving
^
office.
i (12)
The IIT should provide the licensee with a copy of Guideline 4, " Treatment of j
Quarantined Equipment," and Exhibit 3-1, " Guidelines for Review and Availability of l
Tramcripts."
l l
(13)
The IIT leader should request that the licensee establish a liaison for communications l
with the IIT who will interface with the administrative coordinator.
l 2.7 Plant Tour of Affected Ea.ui.oment and Systems l
The inst stion of plant equipment and systems involved in the event and other relevant plant facilities (e.g., control room) should be scheduled after the entrance meeting and prior to personnel interviews. During the plant tour, preliminary observations, issues and considera-tions should be written down as a basis for questions to ask of licensee personnel during l
interviews.
Although the IIT will be provided with the necessary equipment to have photographic j
capability, the licensee should be requested to provide this service during the investigation.
I Photographs of equipment should contain something of known size (a ruler, hand, or person) to show the relative size of the object photographed.
2-7 l
Consideration should be given to the use of some black and white photographs for reproduction in the report, r
The photographer should maintain a log that indicates the s'ibject of each photograph. Each photograph should be assigned a number and include a brief description of the subject. The regional representative may be available to assist in identifying information for the photographer.
2.8 Inteniewing_ Personnel Following the plant tour, the IIT should begin the interviews with the most senior individual with direct personal knowledge of the event. Individuals initially interviewed onsite often include: control room operators, the shift technical advisor, plant / equipment operators, security personnel, site management, corporate personnel, health physicists, technicians, casual obsemrs/ witnesses, NRC resident inspectors, and local officials and residents if appropriate. Later in the investigation, when attention is turned to the evaluation of pre-existing conditions or about how agency actions taken may have contributed to the event, additional interviews of licensee or NRC staff may be necessary. The interviews of licensee management personnel are intended to understand the context and priority of actions which were or were not taken. For guidance on conducting interviews refer to Guideline 3.
2.9 Sequence of Events The IIT should compile a detailed sequence of events based on the one provided by the licensee, on information obtained during interviews, and on mateiial specified below and review it with the licensee. The sequence of events is one of the IIT's most important collection of data and must be factual. Exhibit 2-4 contains a sample sequence of events.
The llT should consider, resolve, and integrate relevant information and data. Such information could include:
the licensee's sequence of evem:,
the output from the plant's data logging systems, e
operators' plant logbooks and control room instrumentation records (i.e., strip charts), or e
personnel observations from interviews.
2-8
The sources of information identify.w an event for the sequence of events should be documented for future reference. Areas of uncertainty and contradictory information should be,ursued and resolved by methods such as additional interviews, submittal of written questions to the licensee, or additional analyses of available information.
The IIT's initial sequence of events compilation should be issued in a Preliminary Notifica-tion (PN) within 3 to 5 days after arriving on site (Exhibit 2-5). Prior to issuing the PN, the IIT leader should review the sequence of events with the licensee.
2.10 Ouarantined Equipment List (OEL) and Troubleshooting Action Plans ffAPs)
For specific guidance on the QEL and TAPS, refer to Guideline 4. As noted previously in Section 2.6, item 8, agreements should be reached during the entrance meeting on the preliminary QEL and the fact that troubleshooting maintenance should not begin prior to IIT approval of TAPS. The status of equipment and areas on the QEL should be updated and revised based upon the sequence of events, personnel interviews, data reviews, etc, The regional or resider.t's office should be requested to help monitor this equipment and the implementation of the TAPS.
2.11 IIT Coordination Meetings Periodic progress review meetings are an important coordinating technique for the IIT leader and a way of keeping the licensee and team members current with the progress of team activities. The team should meet at the end of each day to review results obtained by a!!
team members and to plan the team's activities for the following day. The IIT leader should meet with the licensee on a daily basis to discuss the team's activities.
2.12 Status Reoorts and Event Briefings The IIT should prepare and issue a Preliminary Notification (PN) Report at the end of the first day of the investigation. The PN will be prepared by the IIT onsite and transmitted to AEOD for distribution. The PN should provide a brief description of the event, current plant status, current licensee and IIT activities, and the names and phone numbers of IIT contacts. In gcneral, the IIT leader and assistant IIT leader will serve as IIT contacts during the investigation. A sample PN is included in Exhibit 2-5. The PN number is PNO-IIT-(year)-(number of this IIT this year) (letter identifying series of PNs). The IIT should also issue subsequent PNs periodically (every 2 to 4 days while on-site) to update IIT activities for regional and headquarter offices.
When the sequence of events is well understood, the IIT leader should suggest a conference call with the EDO, the Office of Nuclear Reactor Regulation (NRR) or the Office of Nuclear Material Safety and Safeguards (NMSS), AEOD, and the Region to inform them of the team's information and to respond to their questions. If in the course of the investigation 2-9 I
1
_ _ _ _ _ _ _ _ = _ _ - _ - _.
significant rew information is identified, the llT leader should promptly inform the EDO by telephone.
l The IIT leader should provide support to regional and headquarters offices in their development of decisions regarding granting approval for the licensee to restart the facility.
The IIT leader should brief the Regional Administrator and the Director, NRR (or, as appropriate, the Director, NMSS) on the facts surrounding the event. Since the licensee may request restart approval pnor to the issuance of the llT report, it is expected that the IIT leader will coordinate closely with the regional and headquarters offices to provide.' actual information collected by the IIT. Where investigation activities and analysis are not complete, it is expected that the IIT leader will refrain from prematurely committing to specific team findings, to preserve team independence.
. 13 CD3hetion of Information and Recordkeeping Activities All information obtained by team members will be brought to the attention of the IIT leader.
Industry representatives may orally discuss verified factual event-related information to nuclear industry organizations with the approval of the IIT leader. This information should be transmitted only for purposes of prevention, remedial action, or other,imilar reasons to ensure public health and safety. The industry representatives will keep the IIT leader apprised of all information pertinent to the event. Common sense and good judgment must stedominate in this matter.
All investigative interviews should follow Guideline 3, " Conducting Interviews." In general, a nxvid will not be made of discussions between the team and licensee personnel about routine administrative matters.
An administrative cc edinator assigned to the IIT investigation will be responsible for document control. It is important from the outset, however, to distinguish between "information reviewed" and infornetion used to substantiate the sequence of events, team findings and conclusions. The team members should ensure that all relevant documents are provided to the
'inistrative coordinator for proper control and disposition. Documents containing clas<
J or sensitive unclassified information (e.g., proprietary, safeguards) will be appropriateiy identified by the licensee, properly marked on the outside cover, and stored in an appropriate manner (e.g., security container). The final disposit%n of IIT documents is described in AEOD Procedure No.12, " Incident Investigation Team Administrative Requirements."
2.14 Resconding to Press Inquines Consistent with NRC public affairs policy, prompt and accurate responses will be provided to the news media. Press briefings will be conducted as appropriate. One should be scheduled as soon as possible after the arrival of the IIT leader. A second may be desirable when the team completes its site investigation.
O 2-10
(Q)
The Regional Public Affairs Officer could be available onsite to arrange the news conference and be the point of contact for the news media. The Regional Public Affairs Officer, IIT leader, and the licensee should coordinate press conferences and responses to press inquiries.
The IIT leader will be the lead spokesperson for IIT activities and should limit discussions during and subsequent to the news conference to the scope and purpose of the investigation, to the IIT process, and to the team's sequence of events. Information provided to the press about the event should be identified as preliminary and subject to confhmation.
If determined necessary, in consultation with the Office of Public Affairs, a headquarters or a regional representative will be available to participate in the news conference (see Exhibit 2-2).
2.15 Identifying Additional Expertise and Outside Assistance The IIT leader should assess the need for additional expertise, particularly during the initial phase of the investigation.
Obtaining additional NRC or contractor personnel should be considered if curtain aspects of the event are unique and beyond the expertise of existing p
team members, or if the scope or complexity of the event is sufficient to warrant additional superior staff.
NRC personnel are available to conduct nondestructive examination (NDE) activities on a wide variety of equipment and components. A mobile NDE laboratory can be sent to the site if appropriate. NRC personnel are also available to conduct radiatirn surveys and analyses. See Exhibit 1-5 of Guide-line 1 for a description of NDE capabilities.
The IIT leader should discuss requests for additional assistance with the Director, AEOD, who will make the necessary arrangements.
2.16 Industry Participation in the Investigation Industry representatives may participate as full-time members of the IIT. They are expected to perform in the same manner as NRC team members and NRC will accord them the professional status and courtesy accorded NRC team members.
2.17 Parallel Investigations Normally, the IIT conducts the NRC's primary investigation of an event. Consequently, it is expected that other investigations, by the licensee or by industry will be conducted in ways 2-11
that do not interfere with the llT. Should the team's activities be impeded, delayed er limited because of parallel investigations, the IIT leader should try to resolve the problem j
with the licensee and/or appropriate organization. If attempts fail or the situation is not resolved to the satisfaction of the llT leader, the llT leader should immediately bring the situation to the attention of the Director, AEOD, who will coordinate the agency response to the situation with the EDO, Office of the General Counsel (OGC), Regional Administrator, and other NRC ofGces.
In instances where a related investigation is being conducted by another NRC office, such as the Office of Investigation (01) or the Office of the Inspec'er General (OIG), coordination between the two investigative bodies, and between AEOD and the respective NRC office should be established to avoid hindering the efforts of either investigation.
If the Institute of Nuclear Power Operations (INPO) is developing a Significant Event Report (SER) on the event, they will attempt to ensure that the SER is consistent with the facts of the event as understood by the IIT. This will be accomplished by INPO providing a draft of the SER to the licensee prior to issuance. The licensee will coordinate review of the SER with the IIT, and will ensure any inconsistencies are made known to INPO so they can be resolved prior to issuance of the SER by INPO.
2.18 Referral of Investigation Information to NRC OfGees During an llT investigation, the team may learn directly of allegations, potential wrongdoing or information that should be referred to other organizations for followup and disposition.
The llT leader has the responsibility to identify situations warranting referral and te make the appropriate notifications when referral is appropriate. 01 is responsible for investigating allegations of wrongdoing by other than NRC employees or contractors. OlG is responsible for investigating allegations or reports of misconduct involving NRC employees or contractors, it is also the OlG's role to identify NRC program weaknesses and to issue recommendations for effective and efficient agency operations.
.y matter identified during an IIT which falls under the purview of 01 or OlG should be reperted to the appropriate office. Guidelines regarding referral of information to 01 or OlG are contained in NRC Management Directives 7.2 and 8.8 (formerly Manual Chapters 0702 and 0517),
respectively. The regional representative should be able to assist the llT leader in making the appropriate notifications.
2.19 Protecling An Individual's Identity The NRC's inspection and investigatory prognms rely primarily on individuals voluntarily providing accurate information. Some individuals, however, may agree to provide needed information only if they believe their identities will be protected from pubhc disclosure. The NRC's policy with regard to protecting the identity of an individual is set out in Management Directive 8.8, " Management of Allegations" (formerly Manual Chapter 0517). In cases where the IIT leader believes that needed information will only be obtained by providing assurance that the NRC will not release the identity of the individual, the llT leader should i
contact the Director, AEOD, who will coordinate the situation with the EDO, OGC, and the Regional Administrator.
2-12 1
2.20 S&ooena Power and Power to Administer Oath and Affirmation Subpoena power is available to the NRC to assist it in gathering information which is related I
to the agency public health and safety mission. Most investigations conducted are accomplished without the need for a compulsory process because most interviews and information are given voluntarily Consequently, whenever information is considered to be vital to the investigation, and the individual or entity refuses to either be intervie ed or I
provide documentary information, the llT leader should immediately bring the si aation to the attention of the Director, AEOD, who will coordinate the agency response to the situation with the EDO, OGC, and the Regional Administrator.
In general, oaths are administered to ensure that individuals interviewed properly recognize the gravity of the situation. The point at which an oath is administered depends on the circumstances surrounding the interview. When a situation arises where the administering of an oath is seriously being considered, the llT leader should contact the Director, AEOD, t
i who will coordinate the situation.
2.21 Return Site Visit The team should consider scheduling a return site visit (typically about.4 weeks after the event) to review any significant findings from the licensee's investigation, particularly from the troubleshooting activities conducted on quarantined equipment.
2.22 Report Preparation and Presentation An outline of the report should be developed before the conclusion of the onsite investigation and assignments made of specific sections to team members. This phase of the investigation is addressed by Guideline 5, " Preparation of the Incident Investigation Team Report and 4
Followup Staff Actions," which includes a detailed schedule.
Each team member will participate in a complete review of the team's investigative report for technical accuracy and adequacy in his/her particular area of technical expertise. The llT leader will obtain each team member's concurrence on the report signifying that the team member has reviewed the report and that am differences of professional opinion have either been resolved or documented in an appendix to the report. Copies of the llT's fmal report will be provided to the participating team members.
The IIT leader will be expected to orally brief the EDO about the report within about 40 days, with the advance copy of the report sent to the EDO and the Commission within about 45 ('ays, unless the EDO grants relief from these schedules. Following issuance of the advance copy, the team will normally brief the Commission in an open meeting and subsequently the ACRS or ACNW on IIT Tmdings and conclusions. The team's report is also issued in fmal form as a NUREG document.
2-13
...m.
2.23 Exhibits Exhibit 2-1 7
IIT Tean. Irader Checklist Team irader Initial Actions:
1.
Brief team members oa the event, scope of the investigation, and assignments.
2.
Verify that all industry representatives have signed waivers (Exhibit 1-2).
3.
Conduct entrance meeting.
Use stenographers, if available, to transcribe meeting.
Request licensee to post IIT notice (Exhibit 2-2).
Review preliminary QEL (Guideline 4).
e o
Request preliminary sequence of events, e
Review all aspects of IIT.
e Provide the licensee with copies of IIT Guideline 4 and Exhibit 3-1 of Guideline 3.
e Establish an agreement for treatment of quarantined equipment.
4.
Schedule news conference (if desired) l (Guideline 2, Section 2.14).
I 5.
Schedule interviews (Guideline 3).
l l
6.
Establish quarantined equipment list j
(Guideline 4).
l 7.
Arrange for photographic services (preferably the
(
licensee's; see Guideline 2, Section 2.7).
l 8.
Verify the adequacy of administrative support and request additional support as needed.
2-14 1
i
l t
Exhibit 2-1 (continued) i llT Team Leader Checklist Onsite InvestigatiDD 1.
Perform plant tour (Guideline 2, Section 2.7).
2.
Issue PN at the end of the first day (Guideline 2, Section 2.12).
3.
Compile sequence of events (Guideline 2, Exhibit 2-3).
4.
Conference call (AEOD/NRR/NMSS as applicable) to discuss sequence of events.
5.
Issue PN with sequence of events (3-5 days).
6.
Complete interviews of all individuals having a direct knowledge of the event.
O 7.
Complete reviews of troubleshooting action plans and implementation schedule (Guideline 4).
8.
Arrange for Regional personnel to monitor the implementation of troubleshooting action plans.
9.
Schedule a return site visit (if desired).
10.
Develop a report outline (prior to leaving site)
(Guideline 5, Section 5.4).
11.
Conduct closcout team meeting before leaving site.
12.
As requested, brief the Director, NRR (or as appropriate, the Director, NMSS) and the Regional Administrator on the facts surrounding the event, in support of decisionmaking to authorize the affected licensee to resume facility operations.
13.
Convey significant ancillary findings or information outside the scope of the IIT charter to regional management for followup action.
2-15 l
Exhibit 2-2 Etess Conference Guidance Use talking points and fillin the details. The followiac areas should be considered:
e purpose for investigation, explanation of what an llT is and frequency of use, e
e plans and expected length of stay, scope of team expertise, e
what has been determined, brief nontechnical description of the incident (assume that information is already known) and put the event into perspective (danger to public and/or radiological releases),
e scquence of events (if known),
e current plant status, satus of team activities and findings (if any), and o
expected date for report issuance.
Think of questions that you might get and prepare. Typical questions might include the following:
Why was an alert declared and what does this mean?
Was it an operator error?
Were regulations violated?
Was it a near miss?
How does this compare to a previous event?
2-16
Exhibit 2-3 Generic Bulletin Be'rd Notice (Current l> ate)
POST ON ALL BULLETIN BOARDS TO:
SITE PERSONNEL
SUBJECT:
(Date of Event), (Event Description)
The subject incident is being investigated by an independent team of NRC personnel. The purpose of the team is to establish what happened, to identify the probable cause(s), and to provide appropriate feedback to the industry regarding the lessons learned from the incident.
Anyone having imormation or observations that relate to this event, and wishing to communicate this information to the investigating team may contact (IIT leader) or (assistant IIT leader) at (phone number) or (phone number).
O IIT Leader 9
2-17
Exhibit 2-4 Example IIT Preliminary Sequence of Events Initial Plant Conditions:
Unit 2 operating at steady state power of 100%.
Unit 1 in day 24 of a planned 44-day outage.
Non-emergency ac power was being supplied by backfeeding through the main transformer to the unit auxiliary transformers.
Power was being supplied to both emergency 4kV buses from a single transformer (the l A reserve auxiliary transformer).
The other 4kV emergency transformer (the IB reserve auxiliary transformer) was out of service for planned maintenance.
One of the two unit I diesel generators (IB) was out of service for overhaul and inspection.
The "A" loop of residual heat removal (RHR) was providing core cooling with the reactor coolant system in mid-loop at approximately 90 degrees Fahrenheit.
The reactor coolant system was open at several locations for maintenance. The containment equipment hatch was fully open for removal of equipment.
The IB RHR injection valve was closed and out of service leaving only the l A injection valve (which was de-energized open) available for shutdown cooling.
Time
- Description of Event 0920 A lubrication and fuel truck backed into a support post for the 230kV line resulting in loss of power to the l A reserve auxiliary transformer supplying both Unit 1 and one of the Unit 2 emergency 4kV busses. This resulted in a trip of Unit 2, loss of ac power to the Unit i emergency busses, and an undervoltage start of the 1 A diesel generator.
0921 1 A diesel generator tripped All t'mes are EST. Some previous reports of this incident were reported in CST.
2-18
O Exhibit 2-4 (continued) l 0940 Site area emergency declared due to loss of emergency ac power for greater than 15 minutes.
0941 Diesel generator I A restarted as expected when the load sequencer was locally i
reset. Diesel generator l A tripped again.
1 0956 Local emergency start of diesel generator l A was successful and emergency AC power was restored to the l A emergency bus.
0957 Emergency plan initial notincations of the Site Area Emergency (SAE) commenced.
0958 NRC Operations Center notined of SAE.
1000 RHR was recared. The maximum primary coolant temperature reached 136 degrees Fahrenheit.
1013 Completed initial noti 6 cation of required off-site emergency response organizations except for Georgia Emergency Management Agency (GEMA) and Bur!.e County Georgia. (The normal Emergency Notification Network
(~3 (ENN) was out of service in the control room because it is powered by vital y/
power which was lost.)
1015 The SAE was downgraded to an alert.
1016 GEMA is aware of an emergency at Vogtle due to checkout of ENN from the Technical Support Center, but does not receive the details of the SAE.
1026 The olam Tecnnhi support Center (TSC) was activated.
1029 The TSC informed GEMA that the SAE existed but had been downgraded to an alert.
1034 Installation of the steam generator primary manways was completed.
1035 GEMA received a facsimile from South Carolina with the details of the initial l
notification.
10-41 Initial formal notincation of GEMA was completed by the licensee.
1042 The containment equipment hatch was bolted in place.
2-19 i
l
Exhibit 2-4 (continued) 1140 The IB emergency bus was re-energized from its normal transformer (reserve auxiliary transformer IE), which had been out of service for maintenance.
1140 The pressurizer manway was installed.
1238 RHR was shifted to the B RHR pump to facilitate later electrical alignment changes.
1347 Emergency terminated.
1426 The 1 A diesel generatcr was shutdown. Both emergency busses were receiving power from the IB reserve auxiliary transformer.
O
Exhibit 2-5 Example Preliminary Notification Reoort DATE: 11/26/85 PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE--PNO-IIT-85-2B This preliminary notification constitutes EARLY notice of events of POSSIBLE safety or public interest significance. The information presented is preliminary, requires further evaluation and is basically all that is known by the IIT on this date.
FACILITY: Southern California Edison Company Emergency Classification San Onofre Unit I X_ Notification of Docket No. 50-20 Unusual Event
_ Alert
_ Site Area Emergency
_ General Emergency
_Not Applicable
SUBJECT:
Status Report from NRC Incident Investigation Team O
The Incident Investigation Team (IIT) remains onsite gathering data, conducting interviews, inspecting equipment, meeting with the licensee, concurring in licensee action plans and analyzing facts. A preliminary sequence of events has been developed by the IIT and is attached. A set of preliminary hypotheses explaining the significant events has been developed by the IIT and are being investigated.
All interviews should be completed on November 27,1985. All licensee action plans for further troubleshooting and uncovering remaining event related information should be Enalized on November 28,1985. Assuming the combination of information possessed by the IIT and the licensee action plans to uncover additional facts appear adequate to project closure of significant open issues, the IIT intends to depart the site by December 1,1985, and to reassemble in Bethesda, Maryland.
A final status report will be issued prior to the IIT's departure from the site.
CONTACT: [IIT leader]
[ asst. IIT leader]
[ phone number]
[ phone number]
2-21 m
GUIDELINE 3: CONDUCTING INTERVIEWS
(
3.1 Purpose Guidenne 3 provides guidance to ensure interviews are conducted in a uniform, systematic and complete manner.
3.2 Background
The information derived from a personnel interview is often directly proportional to the skill of the interviewer. Planning on the part of the interviewer is necessary to con _ duct the it.terview systematically. Predetermined questions concerning suspect areas should be asked of allinterviewees.
Prior to conducting interviews, the IIT should have been briefed and given an escorted plant tour to obtain an understanding of what had oce Ted r.nd to obtain a general working knowledge of the plant design and layout. Interviews should be conducted as soon as posaible after the entmnce meeting and plant tw to minimize information lost over time from the memories of those involved. High priority should be given to interviewing person-nel on duty at the time of the event to learn about the actions they took and the observations they made.
Most interviews are transcribed by a stenographer to ensure that an accurate record of the interview is obtained, and for the convenience of the Incident Investigation Team (IIT). For those interviews that are transcribed, ensure that the interviewee understands that the transcripts will be transmitted to the NRC's Public Document Rooms where they will be 4
available to the public. When the team writes its report, an accurate, factual record is available to determine the findings and to make conclusions regarding the event. The necessity for note taking is minimized during the interview,-which also eliminates.
contradictory and erroneous information that can result from note taking. Team members 1-can give their undivided attention to understanding the observr. ions and actions of the interviewee during the evera. Explanatory sketches, diagrams, photographs, or written statements are valuable supplements to the interviewee's statements; however, they should not be construed as substitutes for the narrative statement. In general, discussions between the IIT and beensee personnel about routine administrative matters and/or subsequent minor followup questions for clarification do not necessarily have to be transcribed. In those limited cases where the team leader deems it inappropriate to transcribe an interview (i.e.,
i the presence of a st.nographer would be detrimental to free flow of information), the team l
should conduct the ime. view as outlined in Section 3.5 of this guideline, taking detailed notes documenting the conversations between the team and interviewee.
3-1 s,_.,
r
3.3 Scheduling and Team Attendance Interviews should be scheduled through the administrative coordinator, with personnel in 4
decreasing order of event involvement, if ponible, within the staff. An interview schedule should be prepared for each day. The schedule should include the interviewer's name, location, and start time of the interview. Generally, about 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> should be scheduled for each formal interview.
Selection of IIT members that will actively participate as interviewers during the interview should be minituired, and based on team member assignments and technical expertise. A minimum of two IIT members should be present at all interviews A lead IIT interviewer should be appointed for each interview who is responsible for introducing the interviewee to llT members, allaying qualms, explaining and answering questions ahnut the interview process, providing some background on the objective and scope of 8.he llT investigation, ard controlling the interview. The objective shoo!d be to establish an elemen' of iapport.
3.4 Third Party Attendance Interviewees will normally be permitted at their request to have personal counsel or qualified representative accompany them during the interview. Otherwise, third parties, such as licensee management, company counsel, and union stewards, will not normally be permitteu to attend the interviews.
The interviewees may consult with their counsel or qualified representative during the interview. The counsel's or representative's participation in the interview will be generally limited to advising the interviewee and asking brief clarifying questions to ensure that the interviewee has understood tl e questions. tsked by the llT. If the counsel or qualified representative also represent another pason being interviewed, the IIT will normally permit the attendance of that person if the llT is satisfied that attendance will not appreciably compromise its investigation.
The llT normauy will not permit tape recording of 9 e.nterview by the interviewee since the interview will be transcribed and the interviewee wil; be provided a copy of the transcript, if requested.
If :nere are questions about the above policy regarding the rights of interviewees or additional legal advice is necessary or desired, the llT leader should contact the Deputy Assistant General Counsel for Enforcement in the Office of the General Counsel (OGC).
3-2 4
3.5 Interview Guidelines The following gener.'.! guidelines should be fdlowed for conducting interviews:
(1)
Prior to beginning the interview, the lead interviewer should discuss with the inten'iewee the following items off the record:
The purposes of_theducident Investigation Team are to establish what happened, to identny the probable causes, and to provide appropriate feedback to the industry regarding the lessons learned from the incident.
The reason for conducting interviews is to obtain information regarding the actions and obserntions of personnel who were directly involved with the event.
The purpose of transcribine interviews is to aid the team in developing a factual record and as a convenience to minimize the amount of note taking.
The transcripts will be made available for review. The interviewee will hav:.
the opportunity to make corrections where he/she feels that something was transcribed incorrectly or make clarifications to statements which were what was said, but not what was meant. The corrections and clarifications will be included as part of the transcript.
Transcripts will be made publicly availahk in the NRC's public document room at the conclusion of the investigation and after the issuance of the team's report. At that time, if requested, a copy el the transcript will be provided to the Nerviewee.
Third parties attend interviews caly at tne request of the interviewee. See (3) l l
below.
(2)
Questions regarding protection of the interviewee's identity should be referred to the Director, AEOD who will coordinate the request uith the EDO, OGC, and the Regional Administrator. See also Section 2.19.
(3)
The interview should begin by having the interviewers identify themselves and place on record the date and time the interview commenced. The interviewer should establish the identity of the interviewee. The interviewee should state his/her employer, job title, and provide a brief employment history.
'4)
If a third party is present during the interview, the interviewer should establish on the l
record at the beginning of the interview that the presence of the third party was requested by the interviewee as his/her representative, and indicate the person's name, 3-3
~.
. =
job title, and association with the interviewee. If the third party has attended or will likely attend other interviews and/or will represent others (e.g., the licensee), the team should establish that the interviewee is aware of this fact and nonetheless desires i
the third party's attendance.
(5)
The interview should begin by allowing the interviewee to tell what happened in his or her own way, starting from a time well before the event, but at a point well defined in the interviewee's mind (e.g., start of shift, lunch break). The interviewee should be allowed to tell what happened with little or no interntpftens by the interviewer.
(6)
Note taking during the interview by llT personnel should be minimal and unobtrusive, and should cease if it is distracting the interviewee.
(7) i'o!!owup questions should be kept simple; avoid jargon or terminology that could be foreign to the interviewee. Ile objectiv:. Avoid questions answerable with a simple "yes" or "no". Qacstions such as " is it fair to say..." or "would you agree that..."
are useful ways to communicate that the interviewer understands what the interviewee said. "Can you tell me anything more?" is a good question to ask frequently for subsequent explorations.
(8)
Documents presented or used during the interview should be referenced and entered into the transcript as an exhibit, assigned a number and provided to the stenographer to be included as a part of the transcript.
(9)
At the conclusion of the formal interview, the interviewer should ask the interviewee on the record if there is any other information the interviewee wishes to share with the IIT that has not been specifically covered during the interview, and if the individual knows of any other individuals with knowledge of the event.
(10)
The lead spokesperson should obtain the interviewee's phone number and location where he/she can be reached for subsequent followup questions that may occur, in addition, the lead spokesperson should also provide the phone number and location where he/she can be reached should the interviewee recall additional information to share with the llT.
(11)
A copy of " Guidelines for Review and Availability of Transcripts," Exhibit 31 is to be providt d to all interviewees at the end of each interview.
3-4
1 i
l 3.6 Exhibits l
Exhibit 3-1 i
Guidelines for Review and Availability of TranscrinD i
j The Incident Investigation Team (IIT) has had interviews and meetings transcribed to assist l
the team in its investigation. Interviews should be transcribed overnight and, in general, be i
available for review the following day. Individuals wishing to review their transcripts should bring proper identification with them. Transcripts ofinterviews and meetings are available for review under the following guidelines:
S (1)
During the team's investigation, a copy of the transcripts of personal interviews will be made available for review only to individuals who were interviewed. In the case of joint interviews, each person who was interviewed may examine that transcript.
Individuals may read only their own transcript, and ma) consult with persons.1 counsel while reviewing the transcript. No copies of the transcript may be made.
1 l
(2)
Individuals may correct their answers on errata sheets (see attached form), which will be attached to the transcript rather than on the transcript itself. If anyone wishes to speak further with the llT, the team will be available for further interviews. These interviews will also be transcribed, i
(3)
After the conclusion of the investigation, each individual interviewed, upon request, will receive a copy of the transcript of their own interview for their personal retention ud uw.
(4)
After the repon has been publicly released, the transcripts will be transmitted to the NRC's Public Document Rooms where they will be available to the public.
(5)
Transcripts of meetings between the IIT and the licensee will be available for review by NRC personnel (including the Region) and licensee personnel. The licensee may make corrections on errata sheets, which will be included.with the transcript, rather than on the transcript itself.
(6)
After the llT has concluded its investigation, copies of the meeting transcripts will be provided to the licensee upon request for its retention and use. The transcripts s e also be placed in the NRC's Public Document Rooms unless the licensee has made a request to protect proprietary and safeguards information in the transcripts in accordance with NRC regulations.
3-5
IhluhiL31 (continued) t D18ECTIONS FOR MAKING CORRECTIONS If you have any corrections that you wish to make on your transcripts, please do so on the following page in the following fashion:
Indicate the page to which the correction applies, the line nurnber, the chwge to be made and the reason for making the change. Date and sign all ec tection pages that re. ate to your transcript.
If you have no corrections or clarifications, please state this on the following page and date and sign the conection page.
O 3-6
i i
i l
i t
1 Exhibit 31 (continued) 4,
4 ADDENDUM TO INTERVIEW OF (Name/ Position) 4 i
he Ling Correction and Reason for Correction 2
a 1
b 4
I J
l i
4 5
e t
1 i
4 3
l 4
1 f
P i
I~
I l
l I
l-Page of Signature Date / /
C 3-7 l-
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,,_,ym.,%.,__,..m._....r.,
,y,,....y.,,.,m,,...,_,_,,
,,_,.,,,,...,.,,,....,,...r,,
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(__ ----.-..- -
_~ _ -.. -.. -. _ -.
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i i
i s
l GUIDELINE 4: TREATMENT OF QUARANTINED EQUIPMENT i
i 4.1 Purpose 1
Guideline 4 provides guidance for equipment and areas to be quamntined and related troubleshooting action plans (TAPS) during an incident Investigation Team (llT) investigation.
A11tttihm At all times, the licensee is responsible for quarantined equipment and areas and l
can take action involving the equipment and areas that it deems necessary tot 4
l achieve or maintain safe plant conditions, e
l prevent further equipment degradation, or e
test or hispect as required by the plant's Technical Specifications.
e l
To the maximum degree possible, these actions should be coordinated with the IIT leader in advance or notillcation made as soon as practical l
4.2 Dackgrcund To learn how equipment failed or performed in an anomalous manner during an event, the_
ilT must minimize the potential that the equipment could be manipulated such that important j
information concerning its performance during the event could be lost.- Thus, the Regional l
l Administrator confirms that the licensee has quarantined the equipment in its "as-found" l
condition, usually through a Confirmatory Action Letter (CAL). Then the licensee develops j
a detailed troubleshooting action plan for systematic inspecting and troubleshootbg the j
equipment in order to identify the probable causes for its failure or observed performance.
After the probable cause(s) of failure of a particular component or piece of equipment is i
determined, the equipment is released from quarantine. Instances also could occur at -
l facilities where areas need to be quarantined in order to preserve radiological conditions.
l damage conditions or other conditions in order to properly reconstruct the event.
Hereinafter,' the use of the word *eanipreent" should be interpreted to mean " equipment and area 3."
i i
i The CAL confirms the licensee's intentioxpiar, among other things, that any equipment-l
- hat may have malfunctioned during the : vent oe preserved, except as required for safety;in l
its p, ant condition. Thus, the license is to hold in abeyance all work (i.e.,
j maintenance / testing, etc.) in progrer. or that is planned for the equipment. The IIT leader is i
'4-1 L
m m
authorized to define and revise the quarantined equipment list (QEL), and to review and approve TAPS.
(
4.3 Ouarantined Eauipment List (OEL)
The QEL should be limited to that equipment that signincantly invo.ved in the event. For 1
example, only that equipment that failed or malfunctioned during the event and had an impact on the sequence of events should be included. Equipment can be added or deleted from the QEL as the investigation progresses and remains on the QEL until the IIT leader determines that the probable causes of failure have been identiGed or that its performance was not a signincant contributor to the event. Ouarantining equipment _can result in a signincant disruption to the licensee's activities. so the team should minimize the impact to the maximumicgtte oossible.
The IIT and licensec representatives should reach a common understanding about the scope of the QEL, why each piece of equipment on the initial list is there, and what the boundaries of the quarantine are. Boundaries should include relevant components and/cr systems that may have caused or contributed to the failure or observed performance of the ec,uipment.
If there is a conniet about an item on the QEL that the !!T believes is vital to its i
innstigation, the IIT leader and the licensee should agree on a process to minimize the amount of key information that could be lost. If the conniet cannot be resolved to the satisfaction of the IIT leader, he or she should inform the Director, AEOD, of the problem and obtain guidance for its resolution. The llT leader should review procedures developed by the licensee to meet the limiting condition for operation as well as minimizing the amount of key information that could be lost. The following guidelines govern QEL handling:
(1)
The QEL should be campiled and maintained by the licensee, and reviewed and approved by the IIT.
(2)
The QEL is subject to multiple revisions. The current QEL should contain its revision number, date, and the changes made to it from the previous version.
(3)
The QEL and its revisions should receive prompt and wide distribution including the IIT, NRC OfSces, the Region, and licensee organizations, e.g., as part of the Preliminary Notification (PN) status report.
(4)
Equipment on the QEL should be ;1early identified and secured in the plant (rop'ed-off, tagged out, labeled, etc.) to the extent practicable. A licensee-designated individual for the particular equipment should be identified such that he or she can be contacted when access to the area / equipment is necessary.
4-2
4.4 Trouble 1 heeling Action Plans Establishing TAPS for quarantined equipment are necessary to provide a process by which the probable causes of the conditions observed and equipment malfunctions can be ascertained, it is imponant that the troubleshooting activity on the equipment does not inadvertently result in loss of information necessary to conGrm postulated causes of equipment malfunctions. TAPS ensure that the troubleshooting is systematic, controlled and well-documented, and that adequate records on the as found condition of malfunctioacd equipment are maintained.
A proven method of minimizing the t!me spent in reviewing TAPS, yet ensuring their completeness, is for the llT and licensee to agree on generic guidance that will be part of each TAP and included in the troubleshooting activities. From the generic TAP, specinc TAPS (one for ea:h piece of equipment quarantined) should be developed by the licensee.
The following guidelines apply to the development and use of TAPS:
(1)
For each item on the QEL, a TAP should be developed by the licensee for investigative or troubleshooting work and reviewed and approved by the llT leader prior to implementation, in order to minimize delays, if possible, the llT should complete its review of all TAPS prior to leavmg the site.
(2)
Additional guidance for investigation or troubleshooting equipment is contained in Exhibit 41. An example TAP is provided in Exhibit 4 2. These guidelines and the l
exhibits can servc to Nlp guide the licensee's activities and should be provided for its information and consideration.
l (3)
The licensee should advise the IIT/NRC regional representative as soon as practical of work plans and schedules so that arrangements can be made with the regional office to have NRC staff available to observe troubleshooting activities.
(4)
Repairs and corrective actions on the quarantined equipment should not proceed until the IIT has approved the removal of the piece of equipment from the QEL.
(5)
The TAP must clearly document the scope, affected equipment and the objectives of the troubleshooting activity, and should be a self-contained document that provides a definitive basis for the troubleshooting work. In general, the IIT may review mair.tenance work packages for information, but will not formally approve them.
(6)
The TAP should document all as found conditions, such as any missing, loose or damaged components, and note component conngurations or any abnormal environmental conditions. Whenever possible, photographs should be used to document as-found conditions. When necessary, samples of Guids or their residue l
should be retained for further analysis.
1 OV 4-3
(7)
A cognizant licensee engineer knowledgeable in the design and performance iequirements for the equipment under consideration should be identified to be the point of contact for each TAP.
(8)
The TAP should include or require a review of all known information and data defining conditions existing prior to, during, and after the event. This information should include maintenance, surveillence, and test histories and any changes in design or in the method of operating the equipment and/or system. Significant findings from this review should be used in formulating hypotheses for the probable causes of equipment and/or system anomalies.
(9)
The TAP should include, if possible, a requirement to test the equipment during conditions under which the system, train or component failed to operate properly.
Such tests are extremely desirable when the causes of the faihne are not obvious.
When actual conditions cannot be reproduced, simulated conditions may suffice if their limitation.; are specified on testing results.
(10)
The TAP should indicate the probable causes of the equipment malfunction and include precautions against the destruction of substantiating material evidence.
(11)
The TAP should address the degree of participation by vendor representatives.
Vendor representatives should at least be contated to discuss the performance of the equipment. Their participation should be encouraged if appropriate licensee expertise is not available. Vendor represen'.atives are also expected to follow the action plan.
(12)
The TAP should list the sequence of troubleshooting activities and procedures, if the sequence can be determined prior to the activity being performed, then that sequence should be speciGed, with a check-off for each step. If a speciGc sequence cannot be determined prior to the activity, a general sequence should be identined, with specinc s's ?s documented as they are performed.
(13)
The sequence of troubleshooting activities should include hold points to enable observation and photographic documentation of conditions found. NRC regional staff will normally provide oversight during the troubleshooting activities.
(14)
Repairs or corrective maintenance to equipment should not be part of the TAP.
These aspects will be handled separately by the licensee and the NRC following the troubleshooting process.
(15)
The TAP should specify that when conditions other than what might have been expected based on the developed hypothesis (ses) are noted during troubleshooting, work should cease and appropriate licensee and NRC personnel consulted prior to continuing with the action plan.
4-4
_ ~.. -. - - -
]
1 l
(16)
The TAP should state that all replaced components / equipment should be retained for j
subsequent review and examination, and that complete tracer.bility should be j
maintained. Damaged equipment should not be discarded or shipped offsite without prior llT leader approval. The IIT may require that the failed components be
]
examined by an independent laboratory.
)
I (17)
The completed TAP and the schedule for the implementation of troubleshooting
)
activities should be reviewed by the 11T before completing the initial onsite phase of the investigation. A coordinated approach should be established so that, to the degree i
possible, IIT activities do not unnecessarily delay implementation of licensee recovery i
- actions, i
j (18)
The licensee should notify the llT when the probable cause of each equipment i
malfunction / failure has bxn identified, Agreement should be reached with the
]
licensee on the extent, nature, and schedule of the troubleshooting documentation.
l (19)
Equipment is released from the QEL after the llT leader determines that the probable causes of failure have been identified or that its performance was not a significant contributor to the event.
I i
i 4
i j
45 l
4.5 Exhibits Exhibit 4-1 l
Generie Guidelines for Troubleshooting the hobable Causes of Eculpment Anomalies For each item on the Quarantined Ik uipment List, a troubleshooting action plan (TAP) l should be developed by the licensee for investigative or troubleshooting work which provides the basis for the work instructions. Licensee personnel (lead and/or support) developing the TAP should be identified on the TAP and should have knowledge of the design criteria of the specific area being considered. Vendor engineering support will be utilized as necessary to accomplish this requirement. When used, vendor assistance should be documented.
All troubleshooting activities should be preceded by event evaluaCon and analysis to determine the hypothetical and probable causes of failure or abnormal operation. Conduct the analysis and evaluation as follows:
(1)
Collect and analyze information and operational data for conditions prior to, during, and after the event.
(2)
Review maintenance, surveillan e and testing histories.
(3)
Develop a summary of data including 1 and 2 above, that supports any proposed probable cause of failure or abnormal operation.
(4)
Conduct a change analysis (i.e., what has changed since the last known successful operation of the system or equipment).
(5) liased on items 1-4, develop primary and alternate hypothesis (ses) for the probable cau.se of the problem.
(6)
Develop plans for testing the probable causes and hypothesis (i.e, checks, verifications, inspections, troubleshooting, etc.). In developing inspection and troubleshooting plans, take care that the less likely causes/ hypothesis (ses) remain testable.
(7)
When planning troubleshooting, try to simulate as closely as practical the actual conditions under which the system or component failed to operate properly during the event.
46 1
Exhibit 41 (continued)
It is very important that the investigation not result in the loss of information caused by disturbances to components or systems. Investigations need to be conducted in a logical, well thought-out, and documented manner.
1 4-7
l Exhibit 4-2 i
Eumple Troubleshooting Action Plan frAP)
TITLE: TAP FOR MAIN FEED PUhiP CONTROL SYSTEM Report by:
Chris Tolpram Plan No.1 Tony Grimes Dat: Prepared: June 18,1985 This report has been prepared in accordance with the " Guidelines to Follow When Troubleshooting or Performing Investigative Actions into the Root Causes Surrounding the June 9,19e xeactor Trip," Rev. 2.
I INTRODUC TORY STATEMf1LT This TAP is the first step in addressing Confirmatory Action Letter item 4a, establishing the cause of main feed pump turbine (MPPT) 1-1 trip. Item 4b will be addressed at a later cate.
SUMMARY
OF DATA 4
The following is a discussion of the events which tool: place prior to and shortly after the No.1 MFPT trip on June 9,1985.
On June 9,1985 at approximately 1:22:49 computer alarm Q 626 indicated *MFPT 1 Main Oil Pump 1 ON." This indicates the standbj main oil pump started approximately 12 minutes before No.1 MFPT tripped. The Data Trend Table for No.1 MFPT spee6 indicates that turbine speed increased 29 RPM and then decreased 23 RPM at approximately the same time the standby main oil pump started. This indicates that control valve movement dropped the hydraulic header pressure to < 170 psig, therefore starting the standby main cil pump.
Since the hiDT 20 control system was installed, valve movement, as described above, has started the standby main oil pump due to the quick response of the unit. Anotner indication that the control valves moved is the feedwater flow recorders. Approximately 12 minutes before MFPT l-1 tripped, the charts indicate a change in feedwater flow to both Steam Genera'. ort.
The data available concerning No.1 MFPT trip indicates that the trip was caused by an actual overspeed condition. Recording charts, hooked up after the June 2 problems, show that Limit Switch LS16 was the first indication of a trip. LS16 provides tripped indication of the trip dump valve. Under normal conditions the trip dump valve will trip due to solenoid 4-8
1 E3hibit 4-2 (continued) valve SV-12 energizing, the manual trip lever being actuated, or by the emergency governor plunger due to an overspeed condition. The chart recorders indicate that the hydraulic trip solenoid valve SV-12 did c.ot energize when MFPT l 1 tripped. Therefore, the trip protection devices a.csociated wit!. SV-12 have been eliminated as possible causes of the turbine trip.
Using the computer readout of turbine speed as !n indication for speed change with respect to time, it can be seen that MFPT l-1 increased speed by approximately 1591 IIPM between 1:34:24 and 1:34:53. This change in speed would be more than suf0cient to reach the setpoint for the emergency overspeed plunger to actuate therefore causing the trip dump valve to trip.
The emergency overspeed trip device should actuate between 5866 ItPM and 5984 RPM (reference: MFPT Manual GEK 83602). Testing performed after the MDT 20 was installed j
during the 1984 refueling outage shows that MFPT l 1 tripped on overspeed at 5920 RPM, l
5888 RPM, and 5892 RPM. This testing was performed per PT5136.03, MFPT Overspeed l
Periodic Test, which iequires three consecutive acceptable overspeed trips.
Another indication that MFPT l-1 speed increased is the feedwater flow charts. At approximately 0135 on June 9, a step increase of approximately 2.5 mpph feedwater flow occurred for total feedwater Oow to Steam Generator 1-1 and 12. At this time, MFPT l-1 was in "A'UTO" and MFPT l-2 was in " HAND". This rapid change in feedwater Dow indicates that MFPT 1 1 increased speed, therefore increasing total feedwater flow to the Steam Generators. The turbine speed increased until MFPT l-1 tripped due to an overspeed condition which initiated a plant runback due to a loss of MFPT l-1 above 55% power.
Followir.; the trip MWO l-85-1935-00 was initiated on June 9th to attempt to troubleshoot the cause of the MFPT trip. Under this work order voltage readings were taken on MFPT l-1 and compared to readings taken on MFPT l-2. No significant differences were noted.
All work on this MWO was halted on June 9th.
Maintenance And TesL}]ntory The MDT 20 control system for the MFPTs was installed during the 1984 refueling outage.
After installation of the MDT 20 control system, Test procedure TP520.83, " Main-Feedwater Pump Turbine and Auxiliary Support Systems," was performed to test the equipment.
Testing requested by MP!! Associates, Inc. was performed by TED personnel on installed equipment in November and December of 1984 which included; (1)
A test to establish the dynamic input / output characteristics of the MDT 20.
4-9
hhibiL4-2_im!1tscdj (2)
A test to establish the steady state input / output characteristics of the h1DT 20 valve positioner.
(3)
A dynamie response test of tue h1DT 20 valve positioner.
(4)
A dynanuc response test of the h1DT 20 governor during feedwater flush.
Analysis of these tests by MPR concluded that the h1DT-20 governor will provide satisfactory feed pump differential control wi'h internal settings as recommendcJ by GE and the Integrated Control System (ICS) settings established prior to the outage with the MilC governor.
Discussion of events concerning April 24th trip:
During operation at 98% full power a flux / delta Dux/Dow RPS trip occurred. Approximately eight seconds after the Reactor trip, MFPT l-1 tripped. The cause of the MFPT trip was never positively identified.
Testing was performed to determine if the thrust bearing wear detector trip circuitry could pick up if the standby oil pump is started. Test gauges were installed per MWO l-85-1442-00 in place of the pressure switches and the standby oil pump was cycled to see if pressure would inercase to the trip setpoint. During this testing, pressure did not increase to the trip setpoint. The turbine was also ran through different speed changes to determine if oil pressure could have dropped to trip the turbine. The turbine speed was increased at three different initial speed settings consisting of the following:
(D 3700 RPM to 3900 RPM (2) 3500 RPM to 3900 RPM (3) 3300 RPM to 3900 RPM This testing indicated that the oil pressure did not decay to the trip setpoints.
Periodic test PT 5135.06, "MFPT Emergency Overspeed Governor Tests," was performed to test the overspeed governor. This test was completed successfully.
In addition to the testing which was performed, the followi.. instruments were recalibrated:
(1)
The active and inactive thrust bearing wear detector pressure switches.
(2)
The turbine bearing low oil pressure trip switches.
(3)
The feedpump bearing low oil pressure switches.
i (4)
The main feedpump high discharge pressure trip switches.
(5)
The MFPT vacuum trip switches.
4-10 l
l
Exhibit 4 2 kontinutd)
(6)
The RFR target speed voltage was aojusted from 4.0090 VDC to 3.6045 VDC.
Discussion of events from June 2nd trip:
During main turbine con:rol valve testing, a high turbine vibration signal tripped the main turbine. The ARTS tripped the reactor. Within four seconds after the turbine / reactor trip, both main feed pump turbines tripped.
Pri. Theory The theory behind both the h1FPTs tripping concerns the follov'ng four parameters:
(1)
Rapid Feedwater Reduction (RFR) target speed being set too high due to not adding in a bias to the RFR setpoint.
From January,1985 until April 24,1985, the RFR target speed was thought to be se: at 4800 RPhi, when in fact it was actually 5150 RPM.
Following the April 24 trip, the RFR target speed was thought to be reset to 4600 RPM, when in fact it was actually 5000 RPM.
Reference MWO l-851489 00.
Following the June 2nd trip, it was found that a voltage blas needed to be added to ti.e RFR setpoint. RPR target speed was reset to 4600 RPM. Reference MWO l-851908-00.
(2)
Main steam header pressure increasing to approximately 1070 psig after the reactor tripped causing the MFPT speed to increase.
(3)
Booster feed pump suction pressure increasing due to increasing dearcator level plus dearcator pressure. This would cause main feed pump discharge pressure to increase.
(4)
Feedwater valves partially closing down causing MFP discharge pressure to increase.
lhed on the above four parameters, there is a possibility that the MFPTs tripped on high discharge pressure of 1500 psig, which is one of the trips that could have tripped both pumps almost simultar.cously.
4-11 l
J E5hihiL4-2 (ton @ sed) i Alt. Theory Quick response time associated with the MDT 20 hydraulle control system could cause hydraulic oil pressure swings which could have activated trip circuitry. This theory is not conclusive based on the following:
Testing indicated that the MEPTs would not trip after the hydraulic control system was suSjected to rapid swings by cycling the control valves.
Based on the above theory, the MFPT l-1 (
trol valves were cycled repeatedly through fu!! stroke cycles as fast as possible with the GE representative. This wa; performed to try to decrease the oil pressure to activate trip circuitry associated with the hydraulics. No MFPT l-1 trips were activated. The testing indicates that the MDT 20 hydraulic control system responds from the valves crack point to full open in approximately 0.6 seconds.
Continued testing by GE identified that the #1 MPPT could be tripped when stopping the #2 Main Oil Pump (MOP). If the (2 MOP was left in-service for a period of time and then turned off, the #1 MFPT would not trip. It was recommended by GE nct to turn off the #2 MOP on #1 MFPT until after it had run for awhile. This was only a short-term solution to the problem. The long term solution will be to inspect both MOP discharge check valves alcag with PRV3 during a major outage While increasing power and performing PT5136.01, MFPT Stop Valve Periodic Test, on #1 MPPT, #2 MOP came on during stroke valve testing. The operators left #2 MOP on for approximately 20 minutes as instructed and then shutdown the #2 MOP after which the #1 MFirr tripped. At dl55 the plant was at approximately 56% power and experienced a runback to 55% power.
Repeated testing after the June 5,1985,0155 MFPT l-1 trip:
0630 After stopping the #2 MOP MFPTI-l would trip.
0800 After stopping #2 MOP the MFPT tripped ti"o out of six times.
1400 After stopping #2 MOP the MFPT would not trip. This was performed numerous times with the MFPT on turning gear and at speeds of approximately 4000 RPM's.
1900 Broke vacuum to install additional instru..ientation to monitor the active thrust bearing pressure switches.
4-12
_ _ _. _ ~ _.
j h
2 Exhibit 4-2 (continued) k I
Additional testing was performed and the MFPT would not trip when either #1 or #2 MOP j
was stopped.
GE factory personnel and representative felt that the #2 h10P discharge check valve was sticking open and remained open momentarily after stopping #2 MOP. Under this condition, #1 MOP would pump oil back into the #2 MOP impeller and the 55 psig header pressure would decrease. it is poss.ble that the check valve remained i
open long enough to have the pressure control valve that reduces pressure from 250 to 55 psig (PRV3) to open to maintain header pressure at 55 psig. After the #2 MOP discharge check valve seated, preventing back flow, with PRV3 open, the 55 psig header could experience a pressure surge picking up the thrust bearing wear detector trip circuitry. Eased on repeated testing, the cause for the check valve to remain open evidently cleared itself.
Strip chart recorders were connected to monitor particular electrical signals and oil system pressures after the June 2 trip to deter;nine the cause of MFPT l-1 trip which initiated the reactor trip. The recorders were hooked up to monitor the following information for MFPT 1-1.
4 CTRM Cabinet Room:
(
(1)
Lube Oil Pressure to feed pumps (PS25)
(2)
Bearing Header Pressure (PS19) l (3)
Thrust Bearing Wear (PS 2 & 12) i (4)
Main Feed Pump Discharge pressure (Q628) l (5)
Speed Reference Signal (TPill) i Locally at MFPT l-1:
(1)
Limit switch LS16 (2)
Solenoid valve SV12 (3)
Hydraulic header pressure i
(4)
Control oil pressure (5)
Thrust bearing wear detective (Active)
FAILURE HYPOTHESES SUh1 MARY On the April 24th and June 2nd trips, the reactor tnpped and the MFPT(s) tripped shortly anerward. On the June 9th trip, the MFPT initiated the transient which caused the reactor trip. On the April 24th and the June 2nd trips there was no apparent MFPT overspeed condition. On the June 9th, trip we very clearly saw an indication of a MFPT overspeed 4 13 i.
1 Exhibit 4-2 (continhed) i condition. As a result, we feel that the June 9th trip is unrelated to the previous trips. We will continue to monitor electrical and oil pressure signals.
On June 9, the chart recorder monitoring the speed reference r,ignal shows that demand speed for hiFPT l-1 was steady until actual turbine speed increased and the main feedwater control valves began to close due to the increased feedwater ' low. The ICS speed control for the hiFPTs is derived from the pressure drop across the feedwater control valves and from the feedwater demand signal. Due to a developed feedwater flow error signal, the main feedwater control valves closed down and the pressure drop across the valves increased. The ICS turbine speed control circuitry responded properly by reducing the speed reference signal (demanded turbine speed). This indicates the ICS input signal and the hiDT 20 electronic circuitry which produces the speed referened signal did not cause the ove speed condition.
This also rules out an inadvertent RFR initiation.
An electrical connection problem / malfunction may have developed in the MDT 20 circuitry (excluding the circuity producing the speed reference signal).
Another possible explanation for the overspeed trip is a hydraulic / mechanical control system malfunction which drove the steam control valves open, therefore, causing an overspeed condition.
Another possible cause for the overspeed co~lition could have been a mechanical coupling failure between the pump and turbine. Since feedwater now increased as turbine speed increased, this possibility was ruled out.
An industry poll by hiPR revealed that an overspeed failure occurred in an Indiana power station due to a faulty hiDT-20 speed circuit. A former G.E. Service Representative was i
contacted, and f.e recalled troubleshooting a high speed failure duc to a faulty frequency to I
voltage integrated circuity.
There is indication from the feedwater Dow recorders that the problem may be intermittent, which may make it extremely difficult to locate the problem. This fact is also recognized by G.E.
l CHANGE ANALYSIS Until the 1984 refueling outage, the hiFPTs were equipped with mechanical / hydraulic speed i
governors (General Electric hiodel hiHC). These h1FPTs were replaced with more modern electrical / hydraulic speed governors (General Electric hiodel hfDT-20) installed per FCR 81-l 075.
l (1)
After the April 24. 1985 trip, the following work was performed:
4 14
Exhibit '-2 (continued)
Installed Test gauges on April 24,1985, in place of the active and inactive l'
thrust bearing wear trip pressure switches PS 2715 and PS 2717. Disconnected the test gauges and reconnected PS 2715 and PS 2 717 on 4 25 85 per htWO l-85-1442-00.
4 Recalibrated PS 2715, Active thrust bearing wear trip pressure switch, per htWO l-85145100.
Recalibrated PS 2717, inactive thrust bearing wear trip pressure switch, per htWO l-85-1451-01.
Recalibrated PSL 1161, h1FPT l-1 turbine beanng low oil pressure trip switch, per htWO l-85-1451-02.
Recalibrated PSL 1192,13FP l-1 bearing low oil pressure trip switch, per hiWO l-85-1451-04.
Recalibrated PSH 506, hiFPT l-1 discharge high pressure trip switch, per h1WO l-85-1451-04.
Recalibrated PS 2535A and PS 253511, h1FPT 1-1 low vacuum pressure trip
)
switches, per hiWO 1-84-1451-05.
Recalibrated the Rapid Feedwater Reduction (RFR) Target Speed Setpoint from 4.0090 VDC to 3.6045 VDC which was thought to correspond to 4600 RPht.
l (2)
After the June 2,1985 trip, the following work was performed:
Additicnal h1FPT System test points were monitored and recorded by field mounted strip chart recorders installed per htWO l-85-1887-00 and 01.
l l
Again recalibrated the RFR Target Speed Setpoint from 3.6045 VDC to -2.000 l
VDC which corresponds to 4600 RPhi per hiWO l-851908-00.
l Operational change: #1 hiain Oil Pump was changed from primary t, backup service and #2 hiain Oil Pump was char.ged from backup to primary service, i
Operational change: #2 hiFPT was placed in ICS manual operation from i
automatic operation. #1 h1FPT was left in automatic operation.
S 4-15 l
4 Exhibit 4 2 (continued)
(
ilYPOTilESES INVESTIGATION Based on the information gathered, it appears that several conditions could have caused hiFPT l-1 to overspeed:
(1)
Loose connections associated with the electrical circuitry for the h1DT 20 systern.
(2)
A circuit board component malfunction.
2 (3) 11ydraulic/hiechanical control problem.
ACTION PLAN 1 ALL STEPS OF TlilS TAP ARE TO BE PERFORhiED IN ACCORDANCE WITli TliE LATEST REVISION OF "OUIDELINES TO FOLLOW WHEN TROUBLESHOOTING OR PERFORhilNG INVESTIGATIVE ACTIONS INTO THE ROOT CAUSES SURROUNDING Tile JUNE 9,1985, REACTOR TRIP " ACTION PLAN STEPS WILL DE PERFORhiED IN THE SEQUENCE LISTED.
(1)
LOOSE CONNECTIONS:
Visual inspections and troubleshooting will be performed locally at the pump and at the control cabinet. A log will be maintained to document the troubleshooting performed and the findings. A DVOh! or an osciHoscope will be used to monitor connections while performing these checks.
(2)
CIRCUIT BOARD COh1PONENT h1ALFUNCTION:
Under the directions of a GE representative, using a checklist per the work instructions, an electrical check of the circuits will be performed and no adjustments will be made. A log will be maintained to documtnt the tests performed and the findings. Particular boards of interest are:
Redundar.t Speed Pickup Circuitry Speed Summation & Valve Lift Reference Circuitry Operater & Pilot Valve Position Feedback Circuitry Servo Amplifier Circuitry Function signal generators may be used for input signal 9i 4-16 i
O Exhibit 4-2 (cetinued)
V (3)
HYDRAULIC /MECliANICAL CONTROL SYSTEM:
9 Testing of the hydraulic and mechanical control system will be performed per GE recommendations. Tests such as cycling the valves through full stroke may be performed along with other GE recommended tests. While moving the valves, testing of appropriate electrical signals may also be performed.
Sample oil and inspect filters for contamination.
(4)
If the root cause is not determined from steps 1,2, or 3 then an aux / main steam run of MFPT l-1 will be performed to obtain data to compare to previous information gathered earlier by MPR. GE may also perform additional checks.
(5)
If the root cause is not determined from steps 1,2,3, or 4, then the following will be performed:
The circuit boards will be sent to GE for stress tests in an attempt to locate a failure.
A field wiring check will( performed, such as a megger test.
m 4-17
GUIDELINE 5: PREPARATION OF THE
(
INCIDENT INVESTIGATION TEAM REPORT AND FOLLOWUn STAFF ACTIONS l
5.1 Purpose Guiteline 5 provides guidance for the preparation, release and distribution of the Incident Investigation Team (IIT) report and followup staff actions resulting from the investigation.
5.2 nackground Tile purpose of the incident investigation report is to document in clear and concise ILguage the results of the llT investigation. The Office for Analysis and Evaluation of Operational Data (AEOD) will coordinate with the Director of the Office of Administration to provide staff to assist team members in writing, editing, word processing and printing of the report through the Division of Freedom of Information and Publication Services. Followup staff actions directed by the Executive Director for Operations (EDO) will be based on the report findings and conclusions.
5.3 Writing and Publishing Guidelines These guidcliner, list the sections that typically appear in an IIT report and describe the general approach for how each should be written or by whom it will be compiled. An example of an IIT report table of contents is presented in Exhibit 3-1. A checklist for report preparation is provided in Exhibit 5-2. This section also provides guidelines for the following report preparation requirements:
- submitting graphics material, e transmitting advance copies of the report, and e scheduling preparation of the report 5.4 Report Writing Guidelines (1)
The coler, lille nage, and spjne should be sent to the Automated Graphics Section for preparation by the technical writer / editor assigned to the team.
(2)
The NUREG number will be obtained by the technical writer / editor. The team leader should meet with the technical editor early in the process to review report format and other
- hnical writing issues.
(3)
The abstract should be 200 words or less, and describe the "what, where, and when" about the incident and the "how," as space permits. It should state the team's task,
(
5-1
that it was sent by the EDO, and that the report contains Sndings and conclusions.
The abstract should nel discuss findings and conclusions.
(4)
The table of contents will be compiled by the technical writer / editor.
(5)
The list of figures and tables will be compiled by the technical writer / editor.
(6)
The acknowledgement section should list the names of team meniers and acknowledge any significant assistance the team received in preparing the report.
(7)
The acronyms and abbreviations section will be compiled by the technical writer / editor. In the text, terms for which acronyms are used should be spelled out the Srst time they are used, followed by the acronym in parentheses. Thereafter, the acronym can be used. This practice should be followed for each maior section of the report.
(8)
The report executive summary section should begin with a brief background statement containing the facility's name, utility, location, reactor type (or type of facility process and materials involved), and date licensed for operation. The executive summary should contain a brief description of the incident. In a separate paragraph, the purpose and scope of the IIT should be described, followed by a description of what is contained, section by section, in the remainder of the report. Next should be a summary of the team's conclusions with a short discussion on each conclusion followed by a summary description of the team's findings and conclusions.
(9)
The narrative section of the report tells the story of the incident in chronological order from start to finish, i.me markers should be used throughout the description to keep readers abreast of the sequence. The use of a.m./p.m. clock notations should be used. The use of transitional terms that specify time ("in the meantime," "at this point," "before," "after," "then") should also be used. The narrative should be written in the past tense and descriptions of activities of the people involved in the event should be in the third person, unless someone is quoted directly. The person speaking should be identified by job title. The narrative should not be interrupted with lengthy explanations. A sentence or two of explanation essential for the reader to understand the significance of what is being described is appropriate.
(10)
The system descriotions. response and evaluation seciten should begin by providing a brief overview statement of what function a system or subsystem performs and of how it is integrated with other pertinent systems before a detailed descripuon of the system or sutsystem is given. This should be followed by a narrative of the sequence of events with a description and evaluation of performance. Equipment and systems should be referred to in the same terms consistently. The terms and abbreviations that are used in the text should be identical to those on figures.
5-2
(11)
The human performance considerations section should be written from the point of view of the people who operate or repair the instrumentation and equipment being described. Human performance errors and omissions should be described objectively, not judgmentally. Judgments are appropriate for the conclusions section.
(12)
The precursors sectiori should document all precursor events fully, carefully distin-guishing between facts and opinions. Opinions should be identified as such. In general, this section should pertain to all similar events applicable to the event at the facility, e.g., if it could have happened at that plant, it is a precursor.
4 (13)
A section of signincant items of interest found during the investigation but that were not directly related to the event should be included in the report as needed (e.g., a significant design deficiency that did not play a role in the event was found during the review of a drawing of a system).
(14)
The nndings and conclusions section should distinguish clearly between findings and conclusions. A fmding is what the team learned or "found" based on the factual info. tation collected during the investigation. For example: a piece of equipment faileo; its failure cauwd the loss of a system; operators did not respond quickly to the system failure; procedure manuals did not address this specific sequence of events.- A conclusion states a judgment and specifies the significance or implications of a finding. For example: the equipment failed because of poor maintenance; operators were not properly trained to respond to the sequence of events that occurred; the procedures need to be r: vised to address this sequence of events. The findings and conclusions in this section must be correlated carefully with those discussed elsewhere in the report. The fmdings and conclusions section should not introduce new infor-mation; i.e., nothing should appear as a finding or conclusion for which the basis is not provided in the report; conversely significant issues in the report should be reflected as findings and conclusions.
In general, for early drafts, it is easier to put the findings and conclusions in the text where they logically would occur and to label them with a heading, " conclusions."
This way they can be easily identified when the findings and concl.isions for the entire report must be compared for accuracy and consistency before being compiled in a separate section. In later drafts, they can be collected into a separate section and the labels in the text removed. This system makes it easier to ensure that there is adequate support for each conclusion.
(15)
The reference section should contain only accurate and retrievable references which are essential to establishing the basis or credibility of the IIT report. The reference format style in the NRC Editorial Style Guide (NUREG-1379) is preferred. -The technical writer / editor will assist with the reference format.
53
(16)
The BDDenatces sect!RD should include the IIT charter as Appendix A. Appendix B includes a description of the fact-finding effort and the methodology used by the team in conducting the investigation. This section should include a table of interviews and meetings, identifying those interviewed by job title rather than name. Additional appendices should contain material that clarifies or su19 ements a finding or 1
explanation crucial to the incident but that is so detailed or voluminous that it would impede readers if it appeared in the body of the report.
5.5 Graphie Guidelines The following guidelines provide instructions for submitting work to the Graphics Section.
(1)
All work should be submitted by the origi..ator so that he/she can answer technical questions, if necesary. Figures should be coordinated for editorial and tracking purposes with the technical writer / editor before being submitted to Graphics.
(2)
Original artwork should be submitted when possible.
(3)
For original artwork, instructions should be put in writing. The team member should retain a copy of the artwork and instructions to answer any followup questions the Graphics staff may have.
(4)
Team members should put their names and telephone numbers on the had; of each figure-submitted.
(5)
Artwork for previously published work (from another report or manual), should be submitted in the original or in the best copy available. Changes should be marked on a copy of the original in red.
(6)
If the original appears in a copyrighted source, permission to reproduce it should be obtained before the IIT report is issued. The technical writer / editor will provide the appropriate copyright release form.
(7)
If appropriate, the name of the source from which the original was obtained should be acknowledged.
(8)
For oversized artwork, the original, not a reduced version, should be submitted.
(9)
Changes to existing artwork should not be marked on the tissue overlays. Mark them only on a photocopy of the original.
(10)
The terminology and abbreviations in the text and in the figures should be consistent.
(11)
Equipment diagram symbols should be defined.
5-4
. - - -.. - =--
(12)
Zeros should contain a diagonal line through them to distinguish them from the letter
- 0. Likewise, the letter Z should contain a horizontal line through it to distinguish it from the number 2.
(13)
For photographs requiring callouts (labels), the callouts and arrows should appear on the photocopied version. (No writing should appear on the face of the actual photcgraph.) The orictinal photo and a marked copy should be submitted together. As with other figures, the submitter's name and telephone number should appear on the back of work submitted. Labels should be used to write on the back of the original photograph.
(14)
If the photograph is to be cropped (i.e., only a portion of the original is shown), the crop marks should be marked on a photocopy of the photograph.
(15)
Paper clips should not be used on a photograph without padding.
5.6 hihligtion Forms The following forms are required to be 611ed out in order to publish the IIT report as a NUREG document:
(1)
Form 426, Publications Release for Unclassified NRC Staff Reports. This form is filled out by the technical writer / editor and signed by the IIT leader, u)
Form 335, Bibliographic Data Sheet. This form is filled out by the technical writer / editor.
5.7 Distribution of the Advance Copy It will be necessary to circulate an Advance Copy of the team's investigation report if a Commission briefing is scheduled because the final published NUREG will not be avrilable -
before the briefing. Each copy of the report will clearly indicate on the outside cover that it is an " Advance Copy," and will be stamped for "Of0cial Use Only" (OUO). Information contai.1ed in the report is not to be released publicly until the day of the Commission briefing, when a copy will be placed in the NRC's Public Document Room (PDR). The technical writer / editor will consult with the IIT administrative coordinator to determine the proper report distribution for the Advance Copy. As a minimum, the NRC Commissioners, EDO, Of0cc Directors and Deputy Directors, Regional Administrators, the IIT should be on distribution for an Advance Copy. AEOD will make arrangements to have couriers deliver l
the Advance Copies to the Commissioners and to the EDO as soon as they are available.
3-5 1
, _ ~,, -,.,,... -, - -.
On the day of the Commission briefing, an additional 75 copies of the team's report will be required for the Commission briefing and delivered by courier to the Office of the Secretary 4
on the day of the briefing. Also,25 copies should be provided to OPA for disiribution to the news media. These copies will not be marked OUO or " Advance Copy." The EDO may forward a copy of this version of the IIT report to the affected licensee before the Commission briefing, and simultaneously forward copies of the report to the Public Document Room and the appropriate local PDR. Following the Comminion briefing, the EDO will formally transmit a copy of the team's final investigation repo:t to the licensee and the staff for review and comment. The purpose for this is to allow the 'icensee and the staff an cpportunity to provide comments on the team's report prior to the EDO defining and assigning followup actions to NRC offices. Any subsequent informati(m concerning the final report, such as licensee and NRC staff comments, will also be placed in the appropriate PDR.
5.8 Distribution of the Published NUREG The technical writer / editor will arrange for proper report distribution after consulting with the IIT leader and the administrative coordinator. As a minimum. distribution should be made to NPC Branch Chiefs and above (technical offices only), including Regional Offices, all resident inspectors, and enough copies for all appropriate liceus es. In general, the Regional Administrator of the affected Region should receive 15 copies and AEOD should receive 75 copics of the report. The technical writer / editor should call the Office of Public Affairs, the Advisory Committee on Reactor Safeguards (ACRS), and the Advisory Committee on Nuclear Waste (ACNW) to learn of their requirements.
5.9 Staff Action Determination and Assignment After completion of a draft version of the report, the IIT leader will provide sug a staff actions to the Director, AEOD. The Director, AEOD,* is responsible for developing staff actions to be recommended to the EDO. The suggested followup staff actions are not part of the IIT report. Staff actions will either be generic or plant specific. Generic actions might involve staff review of regulatory requirerr ots, the need for operational experience feedback commumcations, or a review of NRC practices. Plant-specific actions would normally involve rew al or headquarters inspections or reviews of licensee corrective actions following tre event. To the extent possible, suggested foDowup actions should be compiled so as to pull together related findings under a broad-scope action item. Individual actions suggested should be documented sepeately. When compiled, the suggested staff
- The IMrector, AbOD will obtain support as needed from the Diagnostic Evaluation and Incident Investigation Branch.
5-6
l actions will be transmitted as an er. !osure to a memorandum issued by the Director, AEOD, to 4 EDO for consideration and review. The EDO will determine the required staff actions j 8: y icsponsibility to NRC offices as appropriate. Once approved, the staff actions will be forwarded as an enclosure to a memorandum issued by the EDO. Example staff actions are provided in Exhibit 5-3.
5.10 Sfaff Action Status Reconing The EDO staff actions memorandum will require each responsible cffice/ region to provide an action plan within 90 days ano 6-mo.Jh status reports to the EDO with a copy to the Director, AEOD and Chief, DEllB, on the disposition of staff actions. The Director,-
AEOD, will provide to the EDO a status report of all apen llT staff actions, and will compile this information in the AEOD annual report. In addition, closure report (s) will be prepared by the AEOD staff to identify actions taken to tesolve each Gm item. This will normally be prepared as soon as practical after actions are resolved.
5.11 Schedule The IIT shall prepare and transmit its final report to the Commission and the EDO within about 45 days from the time the team is activated, unless the EDO grants an extension of the schedule. The EDO will normally schedule a meeting approximately one vecek after the Advance Copy has been distributed for the IIT to brief the Commission on its investigation.
The following writing / editing schedule provides guidanw to ensure that the report is finished on time.
Day ActWity 1-14 Team's onsite investigation.
15-32 Team members prepare their individual draft sections including findings and conclusions.
Members prepare draft figures an'! select photographs during this period to give -
Graphics adequate preparation time.
Authors /IIT leader review and revise drafts.
33-41 The team assembles an essentially complete draft of the report for each member to review. The Director, AEOD, should be given this draft for information and review. (The purpose of the AEOD review is to provide suggestions to the IIT leader concerning the completeness of the report.)
5-7
Following this review, the team meets to discuss comments on each section and revise the draft as necessary.
The editor reviews each section.
The authors review the editor's comments and resolve problems.
The IIT leader extracts findings and conclusions into a separate section, but leaves findings and conclusions in text.
The Director, AEOD, and the IIT leader discuss suggested followup staff actions.
The team meets to resolve team and AEOD comments. The IIT leader determines which AEOD comments to incorpora.e into the report.
The IIT leader (with the Director of AEOD) briefs the EDO on findings and 42 conclusions.
43 The team makes final review of the complete draft for typos, consistency, and errors, and reviews findings / conclusions for accuracy and consistency. Team members review the same draft (i.e., review sections in series).
The final draft is put into single-space format.
The IIT leader, administrative coordinator and editor review the final text, resolve typos, etc. and the IIT leadcr prepares a transmittal memorandum.
Team members should designate on the bibiliograph"' hose documents used to support findings, sequence of events, or conclusion.
l All team members should concur on the report and on the transmittal l
memorandum.
The editor, IIT leader, and administrative coordinator assemble the final version 44 and have 25 copies of this " Advance Copy" version reproduced for distribution.
l 45-51 Couriers deliver 25 Advance Copies to Con missioners and the EDO.
l 52-59*
IIT presents its report to the Commission. Repidice 75 copies for distribution by SECY to the commission hearing room for publi" ;vailability during the Commission briefing. Provide 25 copies to OPA f',r distribution to the news media.
"IIT Leader Function / Direct Input l
5-8 l
l Published NUREG distributed to staff and public.
The EDO will transmit a copy of the report to tne licensee and staff for review
}
and comment. Copies will also be sent to the PDR.
)
Director, AEOD, and IIT leader will prepare suggested followup staff actions for 4
EDO consideration and review, 60-75 "
The EDO will define and assign followup actions based on the IIT report, comments received from the licensee and staff, and staff requirements memorandum from the Commission, and issue the EDO staff actions to the
.i appropriate NRC offices.
l The team leader will ensure that a lessons learned meeting with the team is
{
conducted.
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- IIT Leader Function / Direct Input l
Need 1-2 week delay to reecive licensee and Commission comments on report for EDO consideration.
5-9
5.12 Exhibits Exhibit 5-1 Example Report Outline I
Abstract II Table of Contents III List of Figures and Tables IV Acknowledgements V
Acronyms and Abbreviations VI The NRC Team for the (Facility Name) Event of (Event Date)
VII Report Body 1.
EXECUTIVE SUhfMARY 2.
NARRATIVE OF THE INCIDENT 3.
SYSTEM DESCRIPTIONS, RESPONSE, AND EVALUATION 4.
HUMAN PERFORMANCE CONSIDERATIONS 5.
SUMMARY
OF INCIDENT PRECURSORS AND RELATED OPERATING EXPERIENCE 6.
SIGNIFICANT ITEMS OF INTEREST 7.
ADDITIONAL ISSUES 8.
FINDINGS AND CONCLUSIONS 8.1 Principal Findings and Conclusions 8.2 Other Findings and Conclusions 9.
REFERENCES
\\Ill APPENDICES A:
IIT Charter 5-10
4 1
i 1
B:
Description of Fact-Finding Efforts J
f
- 1. Investigative Methodology
- 2. Interviews and Meetings l
- 3. Plant Data j
- 4. Quarantined Equipment and Areas 1
i C:
Supplement;l Information 1
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5-11
Exhibit 5-2 11T Team Leader Checklist Benort Preparation and Presentation (Guideline 5_)
1.
Meet with technical editor to review format and other technical writing issues.
2.
Assemble a draft report for team and AEOD review (18 days after return from site).
3.
Develop proposed staff actions.
4 Technical editor review of report.
5.
Brief EDO (28 days after return site).
6.
Final draft assembled (29 days after return site).
7.
Final version assembled and 25 advanced copies reproduced (30 days after return from site).
8.
Couriers deliver advance cop - to Commissioners and EDO (31-37 days after return from site).
9.
Present report to Commission (38-45 days after return from site). Provide 75 copies of report to SECY for public availability during hearing and 25 copies to OPA for distribution to the news media.
- 10. Finalize input oa followup staff actions for EDO consideration.
I1. Ensure that a lessons learned meeting with the team is conducted and document IIT lessons learned for AEOD review (within 14 days after issuance of EDO staff actions).
5-12
.. - = - -
Exhibit 5-3 t
Examole Staff Actions STAFF ACTIONS RESULTING FROM THE INVESTIGA'IION OF MARCH 20,1990 INCIDENT AT VOGTLE, UNIT 1
(
Reference:
NUREG-1410) 1.
Issue:
Adequacy of Shutdown Risk Management
(
References:
Sections 3, 7, 8 and 9
- ~indings 10.1,10.3,10.5 and 10.8, und appendices F, G and K)
During plant shutdown, maintenance and surveillance activities can result in opening of the primary and/or containment systems, stoppage of the shutdown cooling system, disabling electrical systems and movement of heavy equipment within the plant.
Hundreds of plant workers, including contractors, are generally involved. Since, there is an economic incentive for the utility to complete the outage work in an expeditious -
manner, many tasks are performed simultaneously. There is also a need to comply with applicable license conditions, including technical specifications. All of these activiths may be referred to as the outage activities. There is limited NRC guidace on allowai>le plant configurations other than the license conditions and technicsl specification requirements.
Based on Vogtle and other recent events, there appears to be a need to develop further regulatory guidance to ensure adequate risk management during shutdown conditions.
This regulatory concept recognizes the need to operate from time to time during shutdown with less than the usual barriers and safety systems. However, with proper licensee planning, it is believed that the outage should strive to conduct the otherwise more risk significant activities (e.g., mic-loop) at a time when more barriers and systems are in place or operable. Such shutdown risk management does not currently appear to be practiced. While licensees should be responsible for shutdown risk management programs and their implementation, the NRC should develop some generally applicable safety principles.
RESPONSIBLE ACTION OFFICE CATEGORY a.
Review existing regulatory NRR (RES Generic guidance related to shutdown risk as needed) control and issue such new guidance as may be needed. Include in the assessment of shutdown risk management: normal and standby electrical systems and sources, L
5-13
Exhibit 5-3 (Continued)
RESPONSIBLE ACTION OFFICE CATEGORY including switch yard equipment; normal and alternate cooling systems; special alternate plans for loss of forced circulation; fission product barriers including primary and containment systems and special activities such a> movement of heavy loads or construction activities.
b.
Continue to develop shutdown RES Generic risk analysis inethodology and review the effectiveness of alternate cooling methods for bss of forced circulation.
Issue new guidance as appropriate.
c.
Review the present regulatory NRR Generic requirements such as standard technical specifications for shutdown conditions and revise as needed, based on the results for Action (a) above. Develop guidance regarding revision of documents such as EOPs, accident managemen: procedures and plant technical specifications as necessary.
l Issue: Adequacy of Control Over Switchyard Activities
(
References:
Section 5.3 and Finding 10.2)
Switchyard maintenance activities require movement of equipment into and through the l
switchyard. In some cases, these act;vities may require storage of equipment in the j
switchyard. At Vogtle, equipment requiring servicing was stored in the switchyard. A fuel and lubricant truck servicing this equipment initiated the Vogtle incident.
l Administrative control of activities in the switchyard was not adequate to prevent the Vogtle incident. Based on operating events, some industry guidance has been issued regarding events caused by lack of control of activities in switchyards.
i 5-14
Exhibit 5-3 (Continued) i Movement of the truck througc. the switchyard presented an additional hazard because some of the truck's contents were flammable. The Vogtle event potertially could have been more severe had an explosion of the flammable material on the truck occurred. Such an explosion could have caused a loss of nonsafety power further complicating event recovery.
RESPONSIBLE ACTION OFFICE CATEGORY a.
Evaluate the adequacy of NRR (RES Generic existing regulatory guidance as needed) and requirements for the control of activities and hazardous materials in switchyards and protected areas.
Issue new guidance as necessary.
b.
Evaluate the corrective plant-Region 11 Plant-specific speci0c actions taken at Vogtle tu ensure adequate control of activities and hazardous materials in the switchyard.
O I
5-15 1
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NRC Incident Investigation i
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NRC Incident Investigation Program Directive 8.3 pc i
Contents Policy.................................................................
1 O bj ect i ve s............................................................ 1 Organizational Responsibilities and Delegations of Authority..........
2 The Executive Director for Operations (EDO)............................ 2 The Director, Office for Analysis and Evaluation of Operational Data......... 2 Office Directors and Rcgional Administrators............................ 2 De fi n i ti o n s....................................................
2 Augmented Inspection Team (AIT)...................................... 2 Incide nt Investiga tion................................................. 3 Incident Investigation Team (IIT)...................................... 3 s
Significant Operational Event.......................................... 3 p
A pplica b ili ty....................................................
5 E m p l oye e s.......................................................... 5 H a n d b oo k......................................................
5 Re fe re n ces.....................................................
5 L
Approved: August 12,1992 i
7 m asov Oi j
U. S. Nuclear Regulatory Commission
%,...../
Volume 8 Licensee Oversight Programs AEOD NRC Incident Investigation Program Directive 8.3 a
Policy (8.3-01)
The U.S. P Regulatory Commission (NRC) investigates significant ope.
..al events involving reactor and nonreactor facilities licensed :y the NRC. The events may involve responses bp either an Incident ir.,estigation Team (IIT) or the less formal Augmented Inspection Team (AIT) for certain safety significant operational events. These two types of responses are included in the g
Incident Investigation Program.
L Objectives (8.3-02)
To promote public health and. safety and provide for the common defense and security by reducing the frequer:cy of incidents and preventing accidents. (021)
To ensure that signiti. ant operational events are investigated in a manner that is timely, ot@ctive, systematic, and technically sound; that factual information pertaining to the events is documented; and that probable cause(s) are ascertained. (022)
To increase the effectiveness of NRC regulatory programs r.nd licensee operations by the prompt dissemination of the facts, conditions, circumstances, and probable causes of significant operational events and the identification of appropriate followup actions. (023) '
To improve regulatory oversight-of licensee activities by uncovering facts that could show whether the regulatory process before the event contributed directly to the cause or course of the event. (024)
To ensure that IIT 6ndings are properly dispositioned. (025)
O e
Approved: August 12,1992 1
i NRC Incident Investigation Progra.a Directive 8.3 0
Organizational Responsibilities and Delegations of Authority (8.3 03)
The Executive Director for Operations (EDO)
(031)
Approves the innstigation of significant operational events by IITs and is responsible for and ensures that followup actions are taken as a result of each investigation, as defined in Handbook 8.3, Parts I and II.
The Director, Oflice for Analysis and Evaluation of Operational Data (032)
Maintains responsibility for the establishment and maintenance of an NRC investigatory capability and for arranging for the training of designated team members, as defined in Handbook 8.3.
Office Directo:s and Regional Administrators (033)
Participate in the Incident Investigation Program as defined in this directive and handbook.
Definitions (8.3-04)
Augmented Inspection Team (AIT)
(041)
A group of technical experts from the region in which the incident took place, augmented by persor.nel from headquarters or other regions, that performs incident inspections as de5ned in Handoook 8.3, Part III. Its members may have had prior involvement with licensing and inspection activities at the affected facility. The AIT reports directly to the appropriate regional administrator.
O 2
Approved: August 12,1992
NRC Incident Investig: tion Program Directive 8.3
(
Definitions (83-04)(wntinued)
Incident Investigation (042)
A formal process conducted for the purpose of accident prevention that includes the gathering and analysis of information: the determination of findings and conclusions, including the determination of probable cause(s) concerning significant operational events; and dissemination of the investigation results for. NRC, industry, and public review.
Incident Investigation Team (IIT)
(043)
A group of techmcal experts who do not and have not had previous significant involvement with licensing and inspection activities at the affected facility and who perform the single NRC investigation of signiCeant operational events as defined in Handbook 83, Part II. An -
NRC senior manager leads the IIT. Erch IIT reports directly to the EDO and is independent of regional and headquarters office management.
Significant Operational Event (044)
Any radiological, safeguards, or othar safety-related operadonal ev7t at an NRC-licensed facility that poses an actual or a potential hazard to public health and safety, property, or the environment. A significant operational event may also be referred to as arr incident.
The investigatory response is defined by the potential safety significance of the event, the natun. and complexity of the event, and the potential generic safety implications of the event. The levels of investigatory responses are defined as follows:
An IIT performs the single NRC investigation of significant operational events which mayinclude one or more of the following characteristics: (a)
Led to a signi5 cant radiological release, a major release of uranium recovery byproduct material to unrestricted areas, or personnel overexposure. (1)
Approved: August 12,1992 3
NRC Incident Investigation Program Directive 8.3 9
I Definitions (8.3 04)(continued)
Significant Operational Event (044)(continued)
Involved operations that exceeded, or were not included in, the desigu bases of the facility. (2)
Involved an apparent major deficiency in design, construction, or operation having potential generic safety implications. (3)
Led to a site area emergency. (4)
Exceeded a safety limit of the licensee's Technical Specifications. (5)
I.ed to a significant loss of integrity of the fuel, the primary coolant pressure boundary, or the primary containment boundary of a nuc! ear reactor. (6)
Led to the loss of a safety function or multiple failures in systems used to mitigate an actual event. (7)
Involved circumstances sufficiently complex, unique, or not well enough understood, or involved safeguards concerns, or involved characteristics the investigation of which would best serve the needs and interests of the Commission. (8)
An AIT inspects events oflesser safety or safeguards signiscance.
The AIT assesses events whose facts, conditions, circumstances, and probable cause(s) would contribute to the regulatory and technical understanding of a generic safety concern or an importantlesson of experience. The characteristics of these events may include one or more of 'he following: (b)
Multiple failures in safety-related systems. (1)
Possible adverse generic implications. (2)
Complicated and with probable causes unknown or difficult to understand. (3)
Significant unexpected system interactions. (4)
Repetitive failures or events involving safety-related equipment or deficiencies in operations. (5)
Quesnons/ concerns pertaining to either licensee operational or managerial perform:nce. (6) 4 Approved: August 12,1992
I NRC Incident Investigation Program i
Directive 8.3 i
(
Applicability l
(8.3-05) i l
Employees j
(051) 4 The provisions of this directive and its handboek apply to employees of NRC headquarters and regional offices.
4 Handbook
~
(8.3-06)
Major components of the Incident Investigation-Program (i.e.,
incident investigation and augmented inspection) are set forth in Handbook 8.3.
Part I, Incident Investigation -
Pregram.
Establishes j
e l
responsibilities and functions of NRC offices for inddent investigation; defines objectives and authorities; and envides-general guidance. (a) i O
Part II, -Incident Investigation Teams. Outlines Incident e
V Investigation Team (IIT) response, objectives, and authorities; i
provides guidance for development of procedures; and establishes followup responsibilities. (b) l l
Part III, Augmented Inspection Teams. Outlines Augmented l
Inspection Team (AIT) response, objectives, end authorities and l
provides general guidance,(c)
References (8.3-07)
I-l
- 1. NUREG-1303," Incident Investigation Manual."
- 2. NRC Management Directive 8.2, "NRC Incident Response Plan" (formerly MC 0502),
- 3. NRC Management _ Directive 8.5, " Operational Safety Data Review" (formerly MC 0515).
- 4. NRC Inspection Manual Chapter 0325, " Augmented Inspection Team."
i Approved: August 12.1992 5
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NRC Incident Invutigntion Progr:trn Handbook 8.3 Parts 1 - III-
- 1 I
Contents Part I I
Incident Investigation Program Cove ra g e ( A)...........................................................
1 Respo nsibilities (B)......................................................
I 2
j The Executive Director for Operation (EDO) (1)........ -.................
I j
The Director. Office for Analysis and Evaluation of Operational l
D a t a ( AE O D) (2)...................................... _...........
1 j
The Director, Office of Nuclear Reactor Regulation (NRR) (3)...............
2 The Director, Office of Nuclear Material Safety and Safeguards (NMSS)(4)....
3 j
The Director, Office of Administration (5)................................
4 The Director, Office of Personnel (6)....................................
4 Regional Administrators (7)............................................
4 l
The Director, Office of Public Affairs (8).................................
5 l
The Director, Office of Nuclear Regulatory Research (9)....................
5 i
The Office of the General Counsel (10)...................................
6 j
The Director, Office of Congressional Affairs (11)........................,.
6 l
The Office of the Inspector General (12)..................................
6 1
Part II Incident Investigation Teams Objectives of Incident Investigation Teams (A)...............................
7 Scope of Incident Investigation (B).........................................
7 S ch e d ul e ( C)............................................................
8 Team Composition and Qualifications (D)...................................
9 D u ti e s ( E)................................................
9 l
The Executive Director for Operations (EDO) (1)..........................
9 l
The Director, Office for Analysis and Evaluation of Operational Da ta ( AEOD) (2)..................................................
10 Regional Administrators (3)............................................
10 i
Approved: - August 12,1992 i
NRC Incident Investigation Program Handbook 8.3 Parts I - IIf i
Contents (continued)
Part II (continued)
Th e I IT Le a d e r (4)....................................................
11 Conduct of Investigation (F)...............................................
12 Followu p (G )..........................................................
12 Part III Augmented Inspection Teams Objectives of Augmented Inspection Teams (A)...............................
14 Scope of Augmented Inspecticn (B).........................................
14 S ch e d ul e (C)............................................................
15 Team Composition and Qualifications (D)...................................
15 D u ti e s ( E)............,................................................
15 The Director, Office of Nuclear Reactor Regulation (NRR) (1)...............
15 Regional Administrators (2)............................................
16 The AIT lea d e r (3 )..................................................
16 i
AIT Implementing Procedures (F)..........................................
17 Fo ll owup (G )..........................................................
17 i
O ii Approved: August 12,1992
NRC Incident Investigation Program IIandbook 8.3 Part !
O l
Part I Incident Investigation Program Coverage (A)
This part defines the responsibilities and functions of the various offices of NRC in establishing and implementing Incident Investigation Teams (IITs) and Augmented Inspection Teams (AITs).
Responsibilities (a)
The Executive Director for Operations (EDO)
(1)
Determines whether a potentially significant operational event is e
to be investigated by an IIT (see Part II of this handbook). (a)
Selects the IIT leader and team members, provides policy and e
technical direction, and ensures the independence of the IIT. (b)
Concurs with the decision to resume facility operations made by the appropriate regional administrator and office director following an event that involves an IIT response. (c)
The Director, Office for Analysis and Evaluation of Operational Data (AEOD)
(2)
Administers the -Incident Investigation Program to meet the objectives set forth in this directive, with the assistance of other NRC offices. (a)
Ensures that procedures governing IITs are developed, coordinated, approved, distributed, and maintained. (b)
Identifies and provides staff to be members and leaders of IITs and e
AITs (c)
O Approved: August 12,1992 1
NRC Incident Investigation Program IIandbook 8.3 Part I O
i The Director, Office for Analysis and Evaluation of Operational Data (AEOD)
(2) (continued)
Provides administrative support to IITs necessary to achieve e
objectives defined in Part II of this handbook, witn assistance from other NkC etices. (d)
For events that warrant at least an AIT response, consults with the e
appropriate regional administrator and the Director of the Office of Nuclear Reactor Regulation (NRR) or the Office of Nuclear Material Safety and Safeguards (NMSS) to decide if an AIT or IIT response is appropriate. Identifies the potential safety issues and provides recommendations to the EDO on events warranting an IIT response. (e)'
Establishes and maintains rosters of potential team leaden and team members who are certified through formal training in incident investigation, and makes recommendations to the EDO concerning IIT composition. (f)
Identifies needed training and coordinates training requirements e
for IIT candidates through the Technical Training Center. (g)
Assesses the effectiveness of the Incident Investigation Program activities and recommends action, as appropriate, to improve the program. (h)
The Director, Office of Nuclear Reactor Regulation (NRR)
(3)
Ensures that procedures governing AITs are defined, developed, e
coordinated, approved, distribu:ed, and maintained. (a)
Identifies and provides staff to be members and leaders of lits and e
AITs. (b)
Provides assistance in implementing the Incident Investigation
=
Program. (c)
Recommends to and coordinates with the appropriate regional e
administrator on events that may warrant an AIT as defined in Part III of this handbook. (d) 2 Approved: August 12,1992
NRC Incident Investig tion Prograrn Handbook 8.3 Part I O
The Director, Office of Nuclear Reactor Regulation (NRR)
(3)(conti ted)
For events that warrant at least an AIT response, consults with the e
appropriate regional administrator and the Director of AEOD to decide if an AIT or IIT response is appropriate. Identifies the potential reactor safety or reactor safeguards issues and provides recommendations to the EDO on events warranting an IIT response, including the IIT composition. (e)
Discusses with the appropriate regional administrator the acceptability of allowing the affected licensee to resume facility operations following an event that involves an IIT response. (f)
The Director, Office of Nuclear Material Safety and Safeguards (NMSS)
(4) es Identifies and provides staff to be members and leaders of IITs and AITs. (a) e Provides assistance in implementing the NRC Incident Investigation Program. (b)
Recommends to and coordinates with the appropnate regional e
administrator on events that may warrant an AIT as defined in Part III of this handbook. (c)
For events that warrant at least an AIT response, consults with the e
appropriate regional administrator and the Director of AEOD to decide if an AIT or IIT response is appropriate. Identi6es the i
potential nonreactor safety or safeguards issues and provides recommendations to the EDO on events warranting an Irr response, including the IIT composition. (d)
Discusses with the appropriate regional administrator the acceptability of allowing the affected licensee to resume facility operations following an event that involves an IIT response. (e) i ry
]
i
/ pproved: August 12,1992 3
NRC Incident Investigation Program Handbook 8.3 Part I e
The Director, Office of Administration (5)
Provides staff to assist IITs in writing, editing, word processing, printing, and distribution of reports through the Disision of Freedom of Information and Publications Services. (a)
Provides advice and assistance on the protection of classified or sensitive unclassified information related to the incident. (b)
The Director, Office of Personnel (6)
Assists the Technical Training Center with IIT training on an as-needed basis.
Regional Administrators (7)
In coordination with NRR or NMSS, determine those operational e
events warranting investigation by'an AIT and as soon as it becomes clear that at least an AITis warranted-preferably before an AIT is actually established-consult with the Directors of NRR or NMSS and AEOD to consider whether an IIT response is appropriate. Identify the potential safety issues and provide recommendations to the EDO on events warranting an IIT l
response, including the IIT composition. (a) l Select the AIT leader and team members and direct, coordinate, and approve the performance of AITs. (b) l Provide assistance in implementing the NRC Incident l
Investigation Program. (c)
Identify and provide staff to be members and leaders of IITs and e
AITs.(d)
Make appropriate State notifications of NRC responses to operational events. (e)
O 4
Approved: August 12,1992
NRC Incident Investigation Progrcin Handbook 8.3 Part I O) tv Regional Administrators (7)(continued)
For all l'Ts and some AITs, issue a Confirmatory Action 1.etter, as appropriate, to the affected licensee requiring that, within the constraints of ensuring safety, relevant failed equipment and areas are quarantined and subject to agreed-upon controls for troubleshooting; that information and data related to the event are protected; and that the facility is maintained in a safe condition until concurrence is received from the NRC to resume facility operations. (f)
Consult with the Director, NRR (or, as appropriate, the Director, NMSS) to ensure a collegial decision is reached in the matter of granting the affected licensee NRC consent to resume facility operations following an event that involves an IIT response. (g)
The Director, Office of Public Affairs (8)
O
'y~')
Follows established NRC public affairs policies for keeping the press 'and puolic informed of information related to WRC investigatory responses to operational events (see Parts II and III). (a)
Identifies and provides staff to support IITs. (b)
Arranges for press releases and briefings and informs the public of exit meetings, as appropriate. Coordinates these activities with the appropriate headquarters offices, regional administrator, and IIT team leader. (c)
The Director, Office of Nuclear Regulatory Research (9)
Identifies and provides staff to be members and leaders of IITs and AITs. (a) e Provides assistance in implementing the NRC Incident Investigation Program. (b)
LJ 5
Approved: August 12,1992 5
NRC Incident Investigation Program IIandbook 8.3 Part 1 O
The Office of the General Counsel (10)
Provides legal assistance in implementing the NRC Incident Investigation Program. (a)
Identifies and provides legal staff to support IITs. (b)
The Director, Office of Congressional Affairs (11)
Makes Congressional notification, as appropriate, of NRC responses to operational events.
The Office of the Inspector General (12)
Participates as an observer during IITs in coordination with the Director of AEOD.
O O
6 Approved: August 12,1992
NRC Incident Investigation Progrcrn i
Handbook 8.3 Part II O
Part II Incident Investigation Teams This part defines the investigatoryinitiative involving a response by an Incident Investi ation Team (IIT).
F Objectives of Incident Investigation Teams (A)
Conduct a timely, thorough, systematic, fornial, and independent e
investigation of certain safety-significant events occurring at facilities licensed by the NRC.
Collect, analyze, and document factual information and evidence suf5cient to determine the probable cause(s), conditions, a-l circumstances pertaining to the event.
Scope of Incident Investigatiuw (a)
The investigation performed by an IIT emphasizes factfinding and determination of probable cause for a significant operational event (as defined in this directive). The scope of the investigation must be sufficient to ensure that the event is clearly understood, the relevant facts and circumstances are identified and collected, and the probable cause(s) and contributing cause(s) are identified and substantiated by the evidence associated with the event. The investigation must consider whether licensee and _ NRC activities preceding and contcibuting to the event were timely and adequate.
The scope of an IIT must include conditions preceding the event, event chronology, systu response, human factors considerations, equipment performance, precursors to the event, emergency response, safety significance, radiological considerations, and findings and conclusions. The scope of the IIT will be established by a charter attached to the initiating EDO memorandum.
O Approved: August 12,1992 7
NRC Incident Investigatim Program llandbook 8.3 Part II O
Scope of Incident Investigation (n)(continued)
The scope of the investigation must not include-Specific assessment of violations of NRC rules and requirements: (1)
Review of the design and licensing bases for the facility, except as necessary to assess the cause for the event under investigation:(2)
Assessment of reasonable assurance of offsite emergency response capabilities of State and local agencies; or (3)
Determination for resumption of licensed operation. (4)
Information collected as part of the IIT process may contribute to a decision to resume facility operations before issuance of the IIT report. Such instances require close coordination between the IIT leader, the regiorial administrator, and the appropriate program office director.
Schedule (c)
The IIT must be activated as soon as practicable atter the safety significance of the operational event is determined and will begin its investigation as soon as practicable after the facility has been placed in a safe, secure, and stable condition. If there is an NRC incident response, the IIT investigation will begin after the incident response is deactivated.
The IIT must issue interim reports at appropria6e intervals outlining the status, plans, and relevant new information related to its investiga%n.
The IIT must prepare and transmit its final report to the Commission and the EDO in about 45 days from activation of the team, unless relief is granted by the EDO. The EDO will normally schedule a meeting, approximately one week after receipt of the final report, for the IIT to brief the Commission on its investigation. Information contained in the report is not to be released until a copy of the final report is placed in the Public Document Room (PDR), which normally occurs during the day of the Commission briefing,if one is conducted. If deemed necessary, the EDO may fonvard a copy of the final report to the affected licensee before the Commission briefing and simultaneously forward a copy of the final report to the PDR. Following the i
Commission briefing, the EDO will transmit a copy of the final report O 8
Approved: August 12,1992 1
NRC Incl; lent Investigation Progr::m Ilandbook 8.3 Part 11 i
l Schedule (c)(continuca) to the licensee and the NRC staff for review and comment before the EDO defines and assigns followup actions to NRC offices.
Team Composition and
{
Qualifications (o)
The IIT will be composed of technical experts selected on the basis of i
their expertise, potential contributiom: to the event under i
investigation, and their freedom from significant involvement in the licensing and inspection of the facility involved or other activities associated with issues that had a direct impact on the course or consequences of the event. The number of members and areas of technical expertise required for each IIT will be determinsd base <1 un the type of facility and characteristics of the evat.
The team leade. and expert members shotiH. to 6 xxtent practicable, be selected from rosters of candidateswho nave been certified through formal training in incident investigation. An NRC senior manager from the Senior Executive Service shall be the team leader.
Duties (n)
The IIT carries out the single NRC factfm' ding investigation of the event and is authorized and responsible for pursuing all aspects of an event that aie within its scope as defined above. NRC response personnel onsite shall provide support as needed to ensure the
. efficient and effective transition to investigation of the event, so as not l
to interfere with plant safety.
The following duties are in addition to the duties def4-d elsewhere in l
this directive and handbook.
l The Executive Director for l
Operations (EDO)
(1)
Approves the' need for an IIT, selects the team leader and members, provides policy and technical directions to the IIT, ano ensura the independence of the IIT. (a)
Concurs with the decision to resume facility operations made by e
the appropriate regional administrator' and office director following an event that involves an IIT response. (b)
Approwb. August 17_1992 9
NRC Incident Investigation Program llandbook 8.3 Part II O
The Executive Director for Operations (EDO)
(1)(continued)
Determines that the investigation was effectively conducted and consistent with the goals of the Incident Investigation Program. (c)
Assigns followup actions associated with the IIT report. (d)
Determines an apropriate method ofindependent assessment for followup actions, depending upon the nature and significance of the UT fndings. (e)
The Director, Office for Analysis and Evaluation of Operational Data (AEOD)
(2)
Provides administrative support to the IIT by aC:ing the tea:n ;
e meet its objectives and schedule. (a)
Provides advice and consultation to the IIT leader on procedural e
matters and suggestions regarding completeness of the IIT report. (b)
Coordinates with the Director, Office of Administration, to e
provide support necessary to publish an IIT report as a NUREG document. (c)
Prepares a single report identifying the resolu: ion cf all IIT e
findings that require followup action. (d)
Regional Administrators (3) e Provide assistance in briefing and providing background information to the IIT when it arrives on site. (a)
Provide onsite support for the IIT during its investigation. (b)
Identify and provide staff to monitor licensee troubleshooting activities to assess equipment performnce. (c)
Consult with the Director. NRR (or, as appropriate, the Director, e
NMSS) to ensure a collegial decision is reached in the matter of granting the affected licensee NRC consent to resume facility operations following an event that involves an IIT response. (d) 10 Approved: August 12,1992 l
=.
NRC Incident Investig; tion Progr rn IIandbook 8.3 Part II O
The IIT Leader (4)
Directs and manages the IIT in its investigation and ensures that the objectives and schedules are met for the investigation as j
defined in this directive and handbook. (a)
Identifies, adds, end removes equipment and areas from the quarantined list, within the constraints of ensuring plant safety and equipment testing and maintenance requirements and determining causes for equipment anomalies. (b)
Works with the Office of Public Affairs in providing the n%
media with informadon on IIT activities. (c)
Serves as principal spokesperson for the IIT activities in interacting with the licensee, NRC offices, the Advisory Committee on Reactor Safeguards (ACRS), news media, and other organizations on matters involving the investigation. (d)
Prepares frequent status reports documenting IIT activities, plans, significant findings, and safety concerns that may require timely (3
remedial actions or issuance of information notices, bulletins, or
()
orders.(e)
Receives direction and supervision from the EDO. (f)
Identifies and requests thst the EDO provide additional IIT i
resources (e.g., additionai members, consultants, contractor assistance) as needed. (g)
Identifies and recommends to the EDO the need for further studies i
i and investigations, such as staff performance in regulatory activities before the event, when significant concerns could not be thoroughly evaluated because of time or resource limitatNns. (h)
Ensures, in cooperation with the IIT team members and the technical writer / editor, preparation of the final report within the due date established by the EDO. (i)
Briefs the Director, NRR (or, as appropriate, the Director, NMS3) and the regional administrator on the facts sur ounding the event, in support of decisionmaking to authorize the affected licensee to resume facility operations. (j)
Promptly conveys and documents significant ancillary findings or I
information outside the scope of the IIT charter to regional management for followup action. (k) l O
l Approve 6 August 12,1992 11
NRC Incident Investigation 5,'rogram Ilandbook 8.3 l' art 11 Conduct ofInvestigation (F)
The investigation process is based on the principles of incident investigation provided in (IT training programs and described in NUREG-1303. "Incidua Investigation Manual."
The team composition of the IIT must be structured and the procedures developed to maintain independence and objectivity.
Personnel possessing a high degree of independence, ingenuity, and resourcefulness should be selected to ensure that the investigation is conducted ir. a timely, profersional, thorough, and coordinated maaner. (1)
Implementing Procedures. Procedures to guide and control the estaolishment and investigatory activities of an IIT are included in NUREG-1303, " Incident Investigation Manual," and AEOD Procedure No.12. " Incident Investigation Team Administrative Requirements." These procedures provide guidance for-(2)
Activating an IIT, including responsibilities, coordination, communication, team composition, and guidance. (a)
Outlining an IIT investigation of an operational event, including responsibilities, work
- plan, communication, interfaces, scope, and schedule. (b)
- Inteniewing personnel. (c)
- Collecting and maintaming records, documents, data, and other information. (d)
Tre< ting quarantined equipment and areas. (e)
Preparing, reviewing for classified / sensitive unclassified information, and distributing the IIT report and related documents. (f)
Defining administrative support requirements for an IIT. (g)
Followup (o)
Following review and comment by the NRC staff and the licensee on the IIT report, the EDO shall identify and assign NRC office responsibility for generic and tacility-specific actions resulting from the investigation that are safety significant and warrant additional attention or action. Office directors shall provide a written status t
l 1
Approved: August 12,1992 l
l
NRC Incident Investig: tion Progrcm Handbook 8.3 Part 11 1
4 j
Followup (o)(continued) l report on the disposition of each assigned action as directed by the
{
EDO.
The memorandum assigning followup actions should address all IIT findings, including those that are judged to require no followup action, in order to document the consideration of all findings. The resolution of facility specific items will be documented in a single Safety Evaluation Report and each generic item will be individually tracked i
by the EDO's Work Item Tracking System (WITS). In addition, a l
single closcout report will be prepared by AEOD with input from other offices to identify the resolution of each finding.
I Each resolution of an IIT finding will be subject to independent assessment ofits adequacy and completeness.The EDO will d2 cide on I
the appropriate method of independent assessment, depending upon the nature and significance of the finding.
l i
(
f i
4
(
i
! Oo
- Approved: A' ugust 12;1992 13
NRC Incident Investig: tion l'rogram llandbook 8.3 Part III O
Part III Augmented Inspection Teams This part defines the investigatory initiative involving a response by an Augmented Inspection Team (AIT).
Objectives of Augmented Inspection Teams (A)
Conduct a timely, thorough, and systematic inspection related to significant operational events at facilities licensed by the NRC.
Assess the safety significance of the event and communicate to regional and headquarters management the facts and safety concerns related to the event so tht appropriate followup actions can be taken (e.g., study a generic concern, issue an information notice or bulletin).
Collect, analyze, and document factualinformation and evidence sufficient to determine the cause(s), conditions, and circumstances pertaining to the event.
Scope of Augmented Inspection (a)
The AIT response should emphasize factfinding and determination of probable cause(s) and should be limited to issues directly related to the event.
The AIT response should be sufficiently broad and detailed to ensure that the event and related issues are well defined, the relevant facts and circumstances are identified and collected, and the findings and conclusions are identified and substantiated by the information and evidence associated with the event.The inspection should consider the adequacy of the licensee's actions during the event.
The regional administrator directing the AIT inspection shall define and revise the scope of the inspection, as appropriate.
14 Approved: August 12,1992
NRC Incident Investigation Program 11andbook 8.3 Part ill O
Schedule (C)
The AIT must be activated as soon as practireble after the safety significance of the event is determined and should begin itsinspection as soon as practicable after the facility has been placed in a safe, secure, and stable condition.
The AIT must prepare and transmit its report to the appropriate regional administrator within 30 days from activation, unless relief is granted by the regional administrator.
Team Composition and Qualifications (D)
The AIT will be composed of technical experts from the responsible regional office, augmenter' by personnel from headquarters or other regions with special technical qualifications to complement the technical expertise of the regional response. The size of the AIT and the areas of expertise will be determined by the regional administrator and coordinated with other NRC offices based on the event and its O
implications.
The AIT leader will normally be selected from the responsible regional office unless lead is transferred to another NRC office by mutual consent through a Task Interface Agreement.
Duties (E)
The AIT is authorized and responsible for pursuing all pertinent aspects of an operational event. The following duties of NRC offices are in addition to those defined elsewhere in this directive and handbook.
The Director, Office of Nuclear Reactor Regulation (NRR)
(1)
Moniters and evaluates the AITprocess and products, and ensures that AIT procedures are properly maintained. (a)
D2fices, develops, coordinates, approves, and maintains the necessary procedures to guide and control AIT activities. (b)-
O l
' Approved: August 12.1992 15
NRC Incident Investigation Program Ilandbook 8.3 Part III Ol I
Regional Administrators (2)
Determine, in coordination with NRR or NMSS, which operational events warrant an AIT response. (a)
Staff, direct, supervise, coordinate, and approve the performance of AITs. (b)
Ensure that the AIT response is initiated, defined, and conducted in a manner that achieves the objectives. (c)
Evaluate if and when the AIT inspection should be upgraded to an IIT and,in consultation with the Director of NRR or NMSS and AEOD, recommend to the EDO that an IIT response is warranted. (d)
Proside adm nistrative support and resources to the Arr in i
assisting the AIT to meet its objectives and schedule. (e) issue a periodic Daily Staff Note to the EDO when an AIT e
response is implemented and provide updates as appropriate. (f)
Identify and request additional expertise far AIT response from other NRC offices. (g)
Identify followup actions needee based on the AIT findings. (h)
The duties defined in this part for a specific AIT may be transferred to another NRC office by mutual consent through a Task Interface Agreement.
l The AIT 12ader l
(3) l Manages the AIT in its intpection and ensures that the objectiver l
and schedules are met for the inspection as defined in this direct.ive I
and handbook. (a)
With the appro<al of the appropriate regional administrator, adds I
and removes equipment and areas from a quarar. tined list (if applicable) within the constraints of ensuring facility safety, determining causes for equipment anon.alies, and testing and maintenance considerations. (b)
Serves as principal spokesperson for the AIT activities in interacting with the licensee, NRC offices, the ACRS, news media, and other organizations on matters involving the inspection. (c) 16 Approved: August 12,1992
l NRC Incident Investig tirn Progrcin
]
Handboo_ k 8.3 Part III
]
f i
The AIT Leader
)
(3)(continued)
Prepares interim status reports documenting AIT actisities, plans, i
and new information. Communicates to NRC offices any j
significant findings and safety concerns that may require timely i
remedial actions or issuance of information notices, bulletins, or orders. (d)
Receives direction and supervision from the appropriate regional i
ndministrator. (e) i AIT Implementing Procedures (F)
)
l AIT implementing procedures are prepared by NRR and, at a i
minimum, include the following:
i A procedure for activating an AIT, including responsibilities, j
coordination, communication, and guidance. (I)
A procedure for AIT investigation of an operational event, including responsibilities, communication, interfaces, scope, and schedule. (2)
Procedures and guidance for the conduct ofinspection activities of an j
AIT are provided in NRC Inspection Manual Chapter 0325,
" Augmented Insoection Team" (included in the investigation manual) and in Inspecion Procedure 93800, " Augmented Inspection Team j
Irnplementing Procedure."
l Followup (G)
Identification, review, and approval of licensee corrective actions, 7
licensee actions before resumption of facility operations, and NRC enforcement actions must be accomplished through the normal orgamzational structure and procedures.
The appropriate regional administrator will initiate followup actions needed based on the AIT findings. Generally, followup actions will be handled through normal office procedures. For example, the regional office might initiate a Task Interface Agreement with NRR to examine a particular issue and track the issue on the region's open item list.
l Specific guidance on resolution and closeout of followup actions will^
be provided in the NRC Inspection Manual and Inspection Procedures.
L p
Approved: August 12,1992 17' i
APPENDlX B k
/" "'%
UNITED STATES
./ ).,. 7 NUCLEAR REGULATORY COMMISSION 6,,' ^- l,li
.a WASH'NGioN D C XMs
\\
~..
NRC INSPECTION MANUAL OEAB MANUAL CHAPTER 0325 AUGMENTED INSPECTION TEAM 0325-01 PURPOSE The purpose of this manual chapter is to incorporate into the NRC inspection program the existing Augmented Inspection Team (AIT) basis and philosophy, currently in NRC Manual Chapter 0513.
NRC Manual Chapter 0513. "NRC incident Investigation Program," defines the authorities, responsibilities, and basic requirements for personnel investigating significant operational events, and characterizes the dif ferences between an AIT and an incident Investigation Team (IIT).
0325-02 OBJECTIVES To establish policy providing for the timely, thorough, and systematic in-spection cf significant operational events by an AIT.
The purpose of an AIT 15 to determine the cause(s), conditions, and circumstances relevant to an event and to communicate its findings, safety concerns and recommendations to NRC management. This manual chapter addresses the following areas:
a.
Authorities, responsibilities, and duties pertaining to activating the AIT, conducting the inspection, and ensuring that inspection findings are properly addressed.
b.
Guidance on selecting operational events for AIT inspections.
c.
Guidance on scFeduling the conduct of Ali inspections.
d.
Team composition and qualifications.
0325-03 AIT ACTlvAT10N - AUTHORITIES AND RESPONSIBILITIES 03.01 Executive Director for Operations (EDO) a.
Resolves conflicts between a Regional Office and/or one or more Pre-gram Offices regarding such matters as the need to initiate an Ali, the Of fice assigned lead responsibility for AIT implementation, and Office representation on an AIT.
a i
B-1 l
Issue Date: 04/18/91
N b.
May upgrade the inspection response f rom alt status to 117 status any time circumstances warrant the upgrade.
03.02 Regional Administrator (or Designee) i a.
Determines which operational events warrant an A!T response.
This decision it to be coordinated with NRR and NMSS.
Deliberations may include considering the appropriateness of other less formal respons-es, such as 3 special regional inspection or an in-depth licensee investigation, in lieu of an Ali.
b.
Determines if a higher level of response (i.e., ar, llT) would be more appropriate, in consultation with Directors of NRR and/or HMSS, and r
AE00.
This consultation should occur when it becomes clear thet at least an AIT response is warranted, but preferably before the Ali is actually activated, c.
Notifies, as appropriate, the Deputy Executive Director for Nuclear Rebctor Regulation, Regional Operations and Research (DEOR) and/or the Deputy Executive Director for Nuclear Materials Safety, Safeguards and t
Operations Support (DEDS) whea the decision has been made to implement an AIT response, d.
Selects the A!T leader (normally from the affet.ted Regional Of fice) and the team members.
Team members may be chosen at large from the NRC staff to obtain the correct technical expertise.
However, it is not necessary that each Of fice be represented on the alt.
In fact, the AIT may be composed of only regional inspectors, e.
Ensures that regional 1.lT selectees are relieved of all other assign-ments while serving as Al'i members, f.
Prepares a written charter for the AIT delineating the scope of the irriaction; limits the scope to issues closely related to the event.
The written charter shall include the basis for the formation of the
- AIT, Obtains headquarters' views on the appropriateness of the AIT charter from the plant Project Manager, wM confers with the Division of Operational Events Assessment, NRR.
9 May transfer lead responsibility for Ali implementation to another Office, by mutual consent, through a Task Interface Agreement.
h.
Considars issuance of a Confirmatory Action Letter (CAL) to the af-fected licensee depending on the circumstances of the event and, as necessary, supports the Ali by coordinating the disposition of CAL commitments with the licensee.
The considerations for issuance of a CAL, and for its content, should include whether equipent that has failed or misoperated should be quarantined and be subjected to agreed upon controls (insofar as such controls would not interfere with the need to observe operational safety requirements),
if a cal. is deemed necessary, the incident investigation Manual. NUREG 1303, provides ample guidance on the purpose, scope and format of a Confirmatory Action Letter, i.
Reports in the Daily Staf f Notes to the E00 when an AIT response has been implemented.
B-2 1ssue Date: 04/18/91 0325
03.03 program Office Directors for Designees) a.
identify and provide staf f to serve as team members and leaders and ensure that the administrative support necessary to dispatch Ali men.
bers in a timely manner is in place.
Ensure that Ali selectees are relieved of all other assignments while serving as AIT members, c.
Confer with the Regional Administrator (or designee) and with the Director of AE00 (or designees) about whether an operational event warrants response by an AIT or an llT.
(NRR,NHSS) d.
Cotrdinate the AIT activation and inspection effort (which includes conferring with the Regional Administrator (or designee) on the appropriateness of the AIT charter), and initiate the followup action needed, based on the findings of the AIT report, when lead responsi.
bility for Ali implementation is transferred to the Of fice.
(NRR.
NMSS) e.
May issue an Order to Show Cause (Order) 11 the licensee and Regional Office cannot agree on the terms of a CAL, i.e., those actions the NRC believes the licensee should take following an event, or if it is deemed appropriate subsequent to the issuance of a CAL to reaffirm the licensee's commitments.
(The Incident Investigation Manual, NUREG 1303', provides additional guidance on the purpose, scope, and format of an Order).
f.
Rcview the AIT report for generic safety implications and initiate O.
followup action and tracking of the issues on a multiplant basis, as appropriate.
Document the results of the review, even if followu' action is not needed.
(NRR,NMSS) 0325-04 CONDUCTING THE AIT INSPECTION - AUTHORITIES AND RESPONSIBillTIES 04.01 Regional Administrator (or Designee) a.
May revise the scope of the AIT charter during the inspection, as deemed necessary, b.
Provides the team leader with an estimate of the duration of the AIT inspection phase (normally less than one week) and when the AIT report should be issued to tne Regional Administrator (every effort should be made to accomplish this within 2 weeks af ter the onsite inspection effort is completed, but up to 3 weeks (or longer) is permissable if circumstances warrant).
c.
Advises the E00 and Directors, NRR, HMSS and AE00 of changes in the circumstances surrounding the inspection of an event that may warrant elevating the inspection to an llT response, d.
Determines need for inspection support from other Offices (such as the Office of Investigations) and consultants.
Provides administrative help, as required, to support the AIT and O
e.
facilitate the preparation of the alt report.
B-3 l
0325 1ssue Date: 04/18/91 i
i I
..,v..,
f.
May handle inquirie$ by the media, public, Government, or headqvarters personnel concerning the status of the alt inspection.
g.
Ensures that the AIT report distribution list includes the Executive Director for Operations (Eud),
Advisory Committee on Reactor Safe-R guards (ACRS), the Commissioners, and within headquarters, the plant R Project Manager, the Document Control Desk (Office of informatien Resources Management), and the Chief. Events Assessment Branch, Divi-sion of Operational Events Assessment.
h.
Initiates followup action needed based on the findings of the AIT report in accordance with the normal organization *1 structure and procedures. For sxample, a regional office may ini,iate a Task In-terface Agreement with NRR to examine a particular plant-specific issue, and then track the resolution of the issue by means of the regional open items list.
In addition, the Division of Operational Events Assessment, NRR, will review the AIT report for generic safety implications and initiate followap action and track;ng of the issues on a multiplant basis, as appropriate.
i.
Documents the disposition of the findings of the AIT report, even if followup action is not needed.
04.02 Augmented Inspection Team (AIT) Letder a.
Receives instructions from the Regional Administrator (or designee) on the scope and estimated schedule of the Ali effort.
1.
Provides input on '.eeded technical expertise (including consul-tants) and recommends.. n members, b.
Supervises the Ali inspection.
1.
Is responsible for conducting the inspection at the site, includ-ing organizing the inspection effort, and directing and '.upervis-ing the f act-finding activities of the team members.
The team menibers report directly to the ;aam leader.
2.
Is responsible for the preparation of the AIT report, and as circumstances warrant, may direct team members to remain together following the inspection to facilitate the preparation of the AIT report.
Team members are assigned to the AIT until released by the team leader, c.
Is responsible for keeping NRC management informed of progress and significant findings of the inspection.
Note:
Inspection ProceMure 93800 is the implementing procedure for this manual chapter.
0325-05 SELECTION OF OPtRATIONAL FVENTS FOR AIT RESPONSES 05.01 Generel Guidance a.
Candidates for AIT response are:
9-4 Issue Date:
04/18/91 0325
l.
Events of lesser potential safety significance than those that satisfy the criteria for lli activation (see NPC Manual Chapter 0513).
(
2.
Events whose facts, conditions, circumstances, and probable caus-es would contribute to the understanding of a generic safety i oncern or some othe,' important leston related to the specific event.
05.02 Event Characteristics.
An Ali response mga result from an event at a facility that 1Tc~Tu3es one or more of the following charecteristics (partial-ly excerpted from NRC Manual Chapter 0513 "NRC incident Investigation P rog ram" ):
a.
Multiple failures in safety-related systems.
b.
Possible adverse generic implications,
- t..
Considered to be complicated and the probable cause is unknown or difficult tn understand, d.
Involves significant or unexpected system interactions, e.
Repetitive f ailurcs or events involving safety-related equipment or deficiencies in operations.
f.
Involves questions / concerns pertaining to either licensee operational or managerial performance.
g.
Significant overexposures to radiation.
h.
Significant radiation, releases of radioactivity, r< r radioactive contamination.
05.03 Additional Guidance on Non-Reactor Events.
The following additional guidence (beyord that contained in NPr, Manual Chapter 0513), characterizes non-reactor events that m,ay warrant the activation of an AIT:
e.
Repaated instances of safeguards infractions that demonstrate the ineffectiveness of facility security provisions (guards or mechanical / electronic surveillancel.
b.
Renated instances of inadequate nuclear material control and account-ing provisions to protect against theft or diversion of nuclear
- material, c.
Failure of a mill tailings dam _with a substantial release of tailings material and solution off site, j
d.
Individual acute overexposures to radiation:
1.
Whole-body dose equivalent (external dose j
or internal dose commitments) 5 t em 2.
Skin 30 rem 3.
Extremities 75 rem B-5 0325 issue Date: 04/18/91 L
. ~
~
e.
Reicase of r 3dioactive material in concentrations which, if tveraged over a 2a-5u, period at the release powt would exceed 500 times the limits spec;fied in Appendix B. Table 11 of 10 CRF Part 20.
f.
Such failure of radioactive material packaging that external radiation levels exceed 10 rads /hr or contaminatio.i vf the packaging exceeds 1000 times the applicable limits specified in 10 CFR part 71.87.
0325-06 SCHEDULE The alt should be activated as soon as practical af ter the safety signifi-cance of the event is determined.
The team members should make every ef fort to respond to an event within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />.
The team should begin its inspection as soon as practicable af ter the f acility has been placed in 6 safe, secure, and stabic condition.
0325-07 TEAM COMPOSITION AND QUAllflCATiOE The A!T should be composed of experts irra the iesponsible Reg 4n31 Of fice, and may be tugmefited !,
persor.nel fron. Headquarters or other Regions with special technical qualifications to complement the uchnical expertise of the Regional response.
The size of the Ali and the areas of expertise will be determined by the Regional Administrator and coordinated with other NRC Of-fices based on the event and its implications.
4 END I
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B-6 i ssue Date: 04/18/91 0325 l
Appendix C f*%
p POLICY ISS.UE June 10, 1985 SECY-85-208 (Notation Vote)
M:
The Ccmissioners Froq:
Villiam J. Dircks-Executive Director for Operations
Subject:
INCIDENT INVESTIMTION PROGRM
Purpose:
To request the Comission's appreval of the staff's plans to improve the existing program for the investigation of significant operational events.
Background:
A recent study by the Brookhaver, N3tional Laboratory (BNL) identified a number of ways in which the NRC program for the investigation of significant operational events could be 5
improved. The staff has reviewed this resort as well as additional coments ot: this subject that Tave been presared by ACR$ und OPE.
In addition, the staff has ccnsidered tie coments provided at the Comission meeting on this subject which was held on May 9,1985.
Discussion:
As a result of this evaluation, the staff has identified a number of changes in the existing program for the investigation of significant incidents that will substantially improve the program and will incorporate the substance of the cocnents and recomendations that have been made by the various groups that have reviewed this issue.
The general concept and character-istics of these changes are given below. The specific details of the changes will be developed during the coming months as the detailed procedures for implementing this pregram are developed.
The incident investigation Program in oroer to ensure that the investigation of significant events is structured, coordinated and form 311y administered, the staff plans to develop and implement an expanded program of event investigation. This expanded ard strengthened program contains two new initiatives.
For the few significant events with clear and serious implications ft public health and safety, an inter-of fice, interdisciplinary team will be formed to conduct a
,O CONTACT:
Frederick J. Hebdon, AE00 492-4480
The Conrnissioners prompt, thorough and systematic investigation of the event.
for a larger number of events with lesser significance or whose implications are not as clear, the regional-based investigation will be augmented by the assignment' of one or more headquarters technical expert (s) who will participate directly and fully in the event investigation and analysis, and preparation of the final report.
The general concept and characteristics of the revised incident investigation program are discussed below.
Siv ificant operational events (reactor and nonreactor) 1.
o will be investigated by a multi-discipline team made up of l
technical experts from the various NRC offices, if neces-sary, additional technical expertise will be obtained from National Laboratories and from technical consultants.
2.
The duties, responsibilities and schedules to be followed will be femally established in an NRC Nanual Chapter and associated supporting procedures. In cases where an incident Investigation Team (!!T) is activated, the Ili will constitute the single NRC fact finding in*!estigation of the event.
3.
Guidance will be developed and documented in the NRC Manual Chapter regardir.g the significant operational avents to be investf<jated by the 11Ts. It is s urrently anticipated that the llTs will investigate Uproximately 2-3 events per year.
4.
Each IIT will be formally established by the E00 based on recomendations from a Regicnal Administrator or a Program Office Director. In order to ensure the maximum degree of independence for the IlTs, each IIT will report directly to the E00.
5.
Each team leader will be selected by the EDO. The team leader will be at the SES level and, to the extent prac-tical will not have had any significant iiirect involve-ment in the licensing or inspection of the subject plant.
6.
The number and con 1 position of each Ili will be established by the team leader from pre-approved rosters based on the characteristics of the specific event to be investig?ted. Team members will be automatically relieved frce existing duties for the duration of the investigation. Care will be taken to ensure that each team contains persons with Atailed knowledge of the
}
O C-2
The Comissioners O
subject plant (e.g., the Resident Inspector) and a sufficient number of persons who are independent of' the licensing and inspection of the subject plant (e.g.,AEOD,RES). To the extent possible, team rembers will be selected on the basis of their tech-nical or operations expertise, potential contributions to the event investigation, 6nd their freedom from significant direct involvement in the Itcensing and inspection of the plant involved or activities directly associated with the event. Candidates for participation on llis will be identified in advance on rosters to be maintained by AE00.
7.
Candidates for team leaders and for IIT members will receive formal training in incident investigation.
To the extent practical, this training will be completed before they are assigned to an !!T.
8.
Procedures will be developed te ensure that sufficient information is provided to IE, NRR, NMSS, or the Regions to enable imediate action to be taken (e.g.,
IE Bulletin, NRC $hutdown Order), if required, while maintaining the independence of the !!Ts.
9.
Each !!T will prepare a single cortprehensive report which will focus on a description of the event fact-finding, identification of the root causefs) of b,
the event, and findings and conclusions. The report wil, be issued simultaneously to the Comission and the E00. Copies of the report will be placed in the PDR and will be forwarded to the ACRS for independent review. Specific procedures will be established for the EDO to initiate appropriate follow-on action:, and
'o formally respend to the lli report. The approval and implementation nt resulting corrective action will fol' low existing procedures, including CRGR review,
- 10. IIT will emphasize the collection and documentatnn of factsal information and evidence associated with the event. The resulting record will include, as appro-priate: documented statements of plant personnel involved with or influencing the event; pertinent records and documents such as Mgs, strip charts, computer printouts, procedures, and maintenance manuals and histories; and other documentation such as photographs and subsequent test and inspection results.
- 11. Coroideratice, will be given: to providing the capa-bility to invite representatives from outside the I:RC (e.g., INPO, NSSS suppliers) to participate in the Ili
((
C-3
The Comissioners investigation; to providing subpoena power to the lif; and to providing the authority to pre empt parallel investigations by cther organtrations if they interfere with the !!*. Investigation,
- 12. Whenever an llT is activated, an (mediately effective Order or Confirmatory Action i.etter, as appropriate, will be issued to the af fected Itcensee requiring that, within the constraints of maintaining plant safety, the equipment is lef t in the 'as found" condition and information and data concerning the event are retained. Specific procedures will be established in the Order or Confirm & tory Action i.etter to pemit the team leader to lift all or part of the order as soon as possible in order to minimite the impact on continued plant operation. Specific proce-dures will be established to ensure that at no time will a ' freeze
- order interfere wita maintaining a plant in a safe and stable condition.
- 13. Investigations will begin as soon as possible after identification of the significance of the event, but consistent with the need-to ensure that the plant is placed in a safe and stable condition. Specific procedures will be estabitsbed to define the rela-tionship between the !!T and the NRC personnel on site who are monitoring ti.e plant to ensure that it is placed and maintair.ed in a safe and stable condition (e.g., Regional Response Team).
- 14. The llTs will be specifically directed to emphastre fact-finding and determination of probable cause and not to specifically search for violations of NRC rules and requirements in order to minimize any adversarial atmosphere during an investigation. Follow on action regarding possible enforcement actions, based on factual infomation developed by an !!T investigation, will remain the responsibility of IE and the Regions.
The information will also be provided to O! and CIA, as appropriate.
- 15. AEOD will administer the incident Investigation Program, including development of the NRC Hanual Chapter, and will provide necessary administrative support to the Ilis.
- 16. It is currently expected that the ili Manual Chapter and supporting procedures and personnel rosters will be prepared and approved on a timesele to allow implementation in early 1986.
- 17. In addition to the investigation of significant operating events by llis, events of lesser signifi-cance which may involve a generic safety concern or f
9 C-4 1
The Comissioners important lesson of experience, will be investigated O
by regional-based personnel augmented by technical experts from headquarters program offices or con.
l tractors. Events warranting this augmented approach will be identified by the Regional Administrator or by a Of rector of IE, NRR, or NM55 and will be coordinated with the appropriate Regional Administra.
tors. These investigations will also emphasize prompt fact-finding, detemination of root cause and
" freezing" of conditions. Added training on technical investigations will be conducted for f.he involved staff.
- 18. Procedures for conducting augmented investigations of less significant events will be developed by IE, reviewed with other NRC offices and incorporated into the IE Manual.
It is expected that these pro-cedures will be available and special training initiated in early 1980.
- 19. In *he interim, sh'uld a significant event occur, the staff response will be consistent with the above policies and practices, to the extent practical.
==
Conclusions:==
The changes in the NRC Incident Investigation Program describad above incorporate the intert of the coments and recomendations inade by the various groups (e.g. BNt., ACRS, OPE) regarding needed improvements in event investigation.
O The revised incident investigation program will ensure that NRC investigations of significant events are conducted in a thorough, structured and coordinated manner that emphasizes fact-finding and dettrmination of probable cause.
Finally as noted previously, the team 1cader and team inembers will be selected on the basis of technical compe-tence and potential contributions to the investig5 tion. To the degree possible, the team will be largely staffed with individuals with no significant involvement with licensing and inspection activities associated with the event or plant. Thus, independence from previous licensing and inspection activities will be achieved. This revised program provides a substantial improvement in the way staff investigates significance events with a minimum of disrup.
tion, increase in resources or realignment of existing office responsibilities.
Recomenda tion:
That the Comission:
1.
Approve the course of action described in this Cumission Paper and in Enclosure 1.
C-5 l
. ~ ~
The Comissioners 2.
Note that a copy of this Comission Paper will be placed in the Public Document Aoom.
Schedulinn:
If scheduled on the Comission agenda, I recomend that this paper be considered at an open meeting. No specific circumstance is known to the staf f that would require Comission action by any particular date in the near term.
[
WilliaN.;\\
C
. Dircks Executive Of rector for Operations Enclosurs-Oraft Memo to C. J. Heltemes fiom W. J. Dircks Commissionars' comments or consent should be provided directly to the Of fice of the Secretary by c.o.b. Thursday, June 2 7, 1985.
Commission Staff Office comments, if any, should be submitted to the Commissioners NLT Thursday, June 20, 1985, with an infor-mation copy to the Office of the Secretary.
If the paper is of such a nature that it requires additional time for analytical review and comment, the Commissioners and the Secretatiat should be apprised of when comments mr/ be expected.
DISTRIBUTION:
Commission *rs OGC OPE O!
OCA OIA OPA REGIONAL OFFICES EDO ELD ACRS ASLDP ASLAP SECY O
C-6
MEMOP.ANDUM 'OR:
C. J. Heltemes, Jr., Director O'
Office for Analysis and Evaluation of Operational Data 1
FROM:
William J. Dircks Caecutive Director for Operations SUBJECT-IKrLEMENTATION OF A REV! SED PROGRM FOR THE INVESTIGATION OF SIGNIFICANT OPERATING EVENTS In order to ensure that the investigation of significant events is strvctured, coordinated, and fomally administered, you are reqsested to develop the necessary guidance for an expanded program of event investigation. This cuidance is to b.: consistent with the comitments and characteristics of the revised pregran for the investigation of significant events as defined in try paper to the Comission dated June 1985.
Specifically, you are rcquested to:
1.
Prepare an NRC Manual Chapter that will define the duties, respons.
ibilities, and schedule for event investigation of significant events.
This Manual Chapter is to contain guidar.ce regrrding the significant operational events to be investigated by an Incident Investigation Team (117).
2.
Prepare personnel resters of candidate llT leaders and members so that an O
lli can be prceptly established. These candidates should be preapproved I
t:y the Office Directors on the basis that if the individual is selected v
for Ili duty, he or she will be automatically relieved from existing assignments.
3.
Develop appropriate training plans for candidate !!T leaders and mem ers l
and provide assistance for arranging for such trainino to be ccr.detted as I
soon as possible.
l 4.
Prepare supporting procedures covering IIT activities. These procedures l
are to irclude the specific points and concerns identified in the Comission Paper.
l S.
Work with ELD to draf t suitable language ard procedures for issuing (and removing) an imediately ef fective Order or Confirv.atory Action Letter requiring that, within the constraints of maintaining plant safety, eqeipment is lef t in the "as (cund" condition and inforeation and data ccccerning the event are retained, i
l l
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V C-7
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11 ABS T R AC T :D3 wo ds or i.sg)
The Incident investigation Manual prescnbes guidelines for the conduct of investigative activities of the U.S. Nuclear itepulatory Commission (NRC) incident investigation Teams (IITs).The purpose of this manualis to provide llTs guidance to ensure that NRC mvestigations of sigmficant events are timely, structured, coordinated, and formally administered.The guidelines are intended to assist the i.westigation rather than limit the mitiatives and good judgment of the !!T !cader or members. the llT leader and team members should use their expetience and those techniques that provide the most
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conhdence in assuring the il l' objectives are athics edJ hese guidelines address llT activation, conduct of Ihe ins estigation, conducting inteniews, treatment of quarantined equipment, preparation of the team report and followup of staf f actions.
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Wuclear Power is nuMet n or eAc,t3 16 FHICL NRC FORM 33s (2-89)
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